Wednesday, February 13, 2019

Wisdom Wednesday: Statins Lower Risk for CV Events in Elders, But Benefits for Primary Prevention Still in Question

Statin therapy lowers the risk for vascular events in adults over age 70, according to a meta-analysis in The Lancet. However, the benefit seems apparent only in those with a history of vascular disease.

Researchers examined data from 28 randomized trials that either compared statin use with nonuse or compared intensive statin regimens with standard treatment. Over 185,000 participants were included, of whom 15% were age 71–75 and 8% were older than 75.

During roughly 5 years' follow-up, statin use or intensive treatment was associated with a significant reduction in major vascular events across all age groups — overall, a 21% reduction in risk with each 1-mmol/L (39-mg/dL) decrease in LDL cholesterol. However, when stratified by history of vascular disease, a significant benefit among those aged 71 and older was limited to those with prior vascular disease.

My Take:
The full article is available online from The Lancet. These findings are strikingly similar to those found with aspirin – it’s best used for patients with a history of cardiovascular disease than for prevention.

Of course, that’s not how statins are prescribed. The online risk assessment test basically recommends using statins starting at age 45, regardless of serum lipid levels. Statistically, more than half of patients suffering their first heart attack have normal or even low cholesterol. Statins work because they reduce inflammation, not because they reduce LDL cholesterol. That’s a side effect of the drug.

The 21% reduction of risk with each 39-mg/dL decrease in LDL cholesterol only holds true until the level is below 100. There are no statistical benefits for lowering LDL beyond 100 yet many physicians strive to drive the levels below 70.

The medical norm for LDL cholesterol is less than 130-mg/dL. However, because the initial goal of statin drug therapy is to drive the LDL below 100, most labs now list the medical norm as less than 100 to reflect the fact that most people over the age of 45 are prescribed a statin drug.

Please note, I stated most are ‘prescribed’ a statin. Patient compliance is significantly lower as many patients refuse to take the drug while others never fill their prescription or fill it and don’t take it.

Bottom Line:
If you are over the age of 70, take a statin drug and have never had a cardiovascular event, please discuss discontinuing the statin with your prescribing physician. Refer them to this study from The Lancet. Regardless of age, consider lifestyle changes to reduce inflammation as a viable alternative to statins.

Source: February 4, 2019 New England Journal of Medicine

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