Heart smart?
Heart smart
Statins may save lives, so why don't more people take them?
By Shari Rudavsky
Posted: February 5, 2009
Read Comments(1)
The bellwether of success for a drug could well be how many times someone poses the question, "Should we be adding this drug to our public water supply?" -- like we already do with fluoride in many communities. For statins, the question pops up more than 680,000 times on the Internet.
Since the introduction of these cholesterol-lowering drugs in 1987, statins have enjoyed a reputation that outstrips those of most other medications. Their good name received another boost this fall from a study that found that even seemingly healthy people can lower their heart disease risk with a statin.
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The trial of about 18,000 people who had normal cholesterol but elevated levels of another biomarker, c-reactive protein (known as CRP and detected in a blood test), found that those who took a statin cut in half their risk of strokes and heart attacks.
Such dramatic findings led the study's authors to cut short the trial and could mean that doctors recommend that millions more of their patients go on statins.
So should most of us consider taking these drugs?
Not so fast, some doctors say.
"Do I think that everyone needs to run out now and be put on a statin just because they have an elevated CRP? No," says Dr. Sheila Gamache, a cardiologist with Community Heart and Vascular.
Patients should consider whether they have a family history of heart attack, high blood pressure or diabetes. Lifestyle issues such as diabetes, smoking, exercise and obesity factor into risk. Age matters, too. Post-menopausal women and older men have higher risks.
The study suggests that doctors might check c-reactive protein in people at an elevated risk for heart disease. If it's high, they could discuss with their doctor whether to take a statin, Gamache says.
These wonder pills can have side effects, such as upsetting your stomach and, in rare cases, damaging your liver, experts say.
"How many people are you going to have to treat with a statin to have a heart attack or stroke be prevented?" Gamache says. "It has big financial and insurance ramifications to say we think we should put aspirin and statins in water."
No one is seriously advocating that at this point.
Still, the American Heart Association could revise its recommendations on statins in its prevention guidelines that it issues in conjunction with the National Heart Lung and Blood Institute, says Dr. Timothy Gardner, the association's president. A group is currently being convened to consider those guidelines.
If guidelines change, as many as 11 million men older than 50 and women older than 60 could find themselves taking a statin, a Yale University study has found. Currently, 33.5 million people in that age range either take statins or have risk factors suggesting they should.
Even without new guidelines, doctors' statin use has increased since the trial was published, Gardner says. Known as the Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin, nicknamed Jupiter, the study helped catapult c-reactive protein into the cardiological limelight.
Despite the study results, it may take a while for treatment guidelines to change.
"The heart association's official position was that the findings from the Jupiter trial were of great interest and need to be carefully analyzed as new guidelines are being developed," says Gardner, also medical director of the Center for Heart and Vascular Health at the Christiana Care Health System in Wilmington, Del. "The guidelines oftentimes lag a bit behind trends in treatment."
Some doctors argue that the findings offer sufficient proof that the guidelines should be revised.
In a study published last month in the American Heart Journal, researchers found that almost 75 percent of all heart attack patients did not have cholesterol levels that signaled their risk beforehand. Almost half of the 136,905 patients studied had cholesterol levels that fell within the optimal range.
These findings combined with those of the Jupiter trial suggest that the current guidelines on cholesterol levels may not be stringent enough, says Dr. Gregg Fonarow, study author and Eliot Corday Chair of Cardiovascular Medicine and Science at the David Geffen School of Medicine at UCLA.
"The levels of LDL cholesterol that are set in the guidelines are allowing the vast majority of cardiovascular events to occur," Fonarow says.
Current American Heart Associations guidelines consider an LDL reading of 100 or less optimal. Levels in the 100 to 129 range are near or above optimal and those above 160 fall in the high range. While other factors may play into heart disease risk, Fonarow says, he would like to see ranges lowered.
In his own practice, Fonarow says, he tends to be "more aggressive" with prevention. More doctors should follow his example, he argues.
"Rather than looking for the next new risk factor or next new test, if we were just applying what we already know now optimally, there would be hundreds of thousands less heart attacks and strokes occurring in the United States," he says.
One fact that cardiologists already recognized and that the trial affirmed is that cholesterol -- typically statins' primary target -- is not the sole barometer of a person's heart disease risk. One can have low cholesterol and still have vascular disease, Community's Gamache says. Or, one can have high cholesterol and not have the condition.
"Your cholesterol level in your bloodstream is not the be-all and end-all of whether or not you have arteriosclerosis," she says. "High sensitivity CRP is another arrow in the quiver to try to make the diagnosis."
A high sensitivity c-reactive protein test is no more a definitive predictor of one's heart disease risk, others point out. (A less-specific version of CRP can range high if a person has a sprained ankle, sore throat or other inflammatory condition.)
Unless a person has additional risk factors for heart disease, it would not make sense to order this test to screen for the condition, says Dr. Yazid Fadl, a Clarian cardiologist.
"If you do that blindly, if you're just ordering this test and basing your decision on this test alone, you are substituting your clinical judgment," he says. "You should never substitute your clinical judgment; this test should only help to sway you to be more aggressive or give you more assurance."
While the experts can hash out what the formal upshot of this trial will be, Gamache agrees that answers will most likely come on a case-by-case basis.
"We're going to wrestle and struggle with this on a big population level, but when you're behind a closed door with your doctor, you need to make an individual decision," she said.
Other options
Statins should not necessarily be frontline therapy for those with elevated cholesterol.
Dr. Yazid Fadl, a Clarian cardiologist, recommends that his patients first try to lose weight if they are overweight, or stop smoking if that applies. Exercise is another common prescription that the Clarian doctor offers his patients.
"If the majority of people can manage that, they won't need a statin because they will have treated themselves," he says. "There's no substitute to living a healthy lifestyle. No pill in the world is going to negate the fast food that you had the night before."
When it comes to diet, Fadl advocates a high-fiber diet along the lines of the Mediterranean regimen -- low in carbohydrates and high in polyunsaturated fats. He also goes by the sobriquet "Dr. Fiber" for his affinity for diets that include 25 to 30 grams of the stuff daily. Not only does fiber decrease one's heart disease risk, it also can help improve weight loss.
IndianaJane wrote:
Statins kill and disable tens of thousands of people in this country. Some internet research shows how many are suffering from muscle problems and mental fog. Statins cause a gross deficiency of CoQ10. Anyone taking statins without supplementing with CoQ10 is asking for big trouble. High cholesterol doesn't cause heart attacks. Anyone who wants this poison in the public water supply is already mentally screwed - probably by the poisonous industrial waste: fluoride.2/5/2009 2:27:50 AM
Statins may save lives, so why don't more people take them?
By Shari Rudavsky
Posted: February 5, 2009
Read Comments(1)
The bellwether of success for a drug could well be how many times someone poses the question, "Should we be adding this drug to our public water supply?" -- like we already do with fluoride in many communities. For statins, the question pops up more than 680,000 times on the Internet.
Since the introduction of these cholesterol-lowering drugs in 1987, statins have enjoyed a reputation that outstrips those of most other medications. Their good name received another boost this fall from a study that found that even seemingly healthy people can lower their heart disease risk with a statin.
OAS_AD('160x600_1');
The trial of about 18,000 people who had normal cholesterol but elevated levels of another biomarker, c-reactive protein (known as CRP and detected in a blood test), found that those who took a statin cut in half their risk of strokes and heart attacks.
Such dramatic findings led the study's authors to cut short the trial and could mean that doctors recommend that millions more of their patients go on statins.
So should most of us consider taking these drugs?
Not so fast, some doctors say.
"Do I think that everyone needs to run out now and be put on a statin just because they have an elevated CRP? No," says Dr. Sheila Gamache, a cardiologist with Community Heart and Vascular.
Patients should consider whether they have a family history of heart attack, high blood pressure or diabetes. Lifestyle issues such as diabetes, smoking, exercise and obesity factor into risk. Age matters, too. Post-menopausal women and older men have higher risks.
The study suggests that doctors might check c-reactive protein in people at an elevated risk for heart disease. If it's high, they could discuss with their doctor whether to take a statin, Gamache says.
These wonder pills can have side effects, such as upsetting your stomach and, in rare cases, damaging your liver, experts say.
"How many people are you going to have to treat with a statin to have a heart attack or stroke be prevented?" Gamache says. "It has big financial and insurance ramifications to say we think we should put aspirin and statins in water."
No one is seriously advocating that at this point.
Still, the American Heart Association could revise its recommendations on statins in its prevention guidelines that it issues in conjunction with the National Heart Lung and Blood Institute, says Dr. Timothy Gardner, the association's president. A group is currently being convened to consider those guidelines.
If guidelines change, as many as 11 million men older than 50 and women older than 60 could find themselves taking a statin, a Yale University study has found. Currently, 33.5 million people in that age range either take statins or have risk factors suggesting they should.
Even without new guidelines, doctors' statin use has increased since the trial was published, Gardner says. Known as the Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin, nicknamed Jupiter, the study helped catapult c-reactive protein into the cardiological limelight.
Despite the study results, it may take a while for treatment guidelines to change.
"The heart association's official position was that the findings from the Jupiter trial were of great interest and need to be carefully analyzed as new guidelines are being developed," says Gardner, also medical director of the Center for Heart and Vascular Health at the Christiana Care Health System in Wilmington, Del. "The guidelines oftentimes lag a bit behind trends in treatment."
Some doctors argue that the findings offer sufficient proof that the guidelines should be revised.
In a study published last month in the American Heart Journal, researchers found that almost 75 percent of all heart attack patients did not have cholesterol levels that signaled their risk beforehand. Almost half of the 136,905 patients studied had cholesterol levels that fell within the optimal range.
These findings combined with those of the Jupiter trial suggest that the current guidelines on cholesterol levels may not be stringent enough, says Dr. Gregg Fonarow, study author and Eliot Corday Chair of Cardiovascular Medicine and Science at the David Geffen School of Medicine at UCLA.
"The levels of LDL cholesterol that are set in the guidelines are allowing the vast majority of cardiovascular events to occur," Fonarow says.
Current American Heart Associations guidelines consider an LDL reading of 100 or less optimal. Levels in the 100 to 129 range are near or above optimal and those above 160 fall in the high range. While other factors may play into heart disease risk, Fonarow says, he would like to see ranges lowered.
In his own practice, Fonarow says, he tends to be "more aggressive" with prevention. More doctors should follow his example, he argues.
"Rather than looking for the next new risk factor or next new test, if we were just applying what we already know now optimally, there would be hundreds of thousands less heart attacks and strokes occurring in the United States," he says.
One fact that cardiologists already recognized and that the trial affirmed is that cholesterol -- typically statins' primary target -- is not the sole barometer of a person's heart disease risk. One can have low cholesterol and still have vascular disease, Community's Gamache says. Or, one can have high cholesterol and not have the condition.
"Your cholesterol level in your bloodstream is not the be-all and end-all of whether or not you have arteriosclerosis," she says. "High sensitivity CRP is another arrow in the quiver to try to make the diagnosis."
A high sensitivity c-reactive protein test is no more a definitive predictor of one's heart disease risk, others point out. (A less-specific version of CRP can range high if a person has a sprained ankle, sore throat or other inflammatory condition.)
Unless a person has additional risk factors for heart disease, it would not make sense to order this test to screen for the condition, says Dr. Yazid Fadl, a Clarian cardiologist.
"If you do that blindly, if you're just ordering this test and basing your decision on this test alone, you are substituting your clinical judgment," he says. "You should never substitute your clinical judgment; this test should only help to sway you to be more aggressive or give you more assurance."
While the experts can hash out what the formal upshot of this trial will be, Gamache agrees that answers will most likely come on a case-by-case basis.
"We're going to wrestle and struggle with this on a big population level, but when you're behind a closed door with your doctor, you need to make an individual decision," she said.
Other options
Statins should not necessarily be frontline therapy for those with elevated cholesterol.
Dr. Yazid Fadl, a Clarian cardiologist, recommends that his patients first try to lose weight if they are overweight, or stop smoking if that applies. Exercise is another common prescription that the Clarian doctor offers his patients.
"If the majority of people can manage that, they won't need a statin because they will have treated themselves," he says. "There's no substitute to living a healthy lifestyle. No pill in the world is going to negate the fast food that you had the night before."
When it comes to diet, Fadl advocates a high-fiber diet along the lines of the Mediterranean regimen -- low in carbohydrates and high in polyunsaturated fats. He also goes by the sobriquet "Dr. Fiber" for his affinity for diets that include 25 to 30 grams of the stuff daily. Not only does fiber decrease one's heart disease risk, it also can help improve weight loss.
IndianaJane wrote:
Statins kill and disable tens of thousands of people in this country. Some internet research shows how many are suffering from muscle problems and mental fog. Statins cause a gross deficiency of CoQ10. Anyone taking statins without supplementing with CoQ10 is asking for big trouble. High cholesterol doesn't cause heart attacks. Anyone who wants this poison in the public water supply is already mentally screwed - probably by the poisonous industrial waste: fluoride.2/5/2009 2:27:50 AM
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