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July 06, 2007

statins

There is much controversy over cholesterol. Most of the establishment is convinced that high cholesterol is a bad thing, for your heart, your brain, and your life. There is good evidence that they are right, found in an association between high cholesterol and increased incidence of cardiovascular and cerebrovascular disease. Of course, the association does not prove causation and there is some evidence that higher cholesterol is cardioprotective in older folks.

But even granting that high cholesterol is bad is far short of demonstrating that lowering cholesterol is life-saving. So there was great rejoicing when the Scandinavian Simvastatin Survival Study (4S) proved a significant decrease in all-cause mortality in 1995. This was tested in a population that were at high risk and had already had heart attacks. (This is called secondary prevention.) The year before, the West of Scotland study tested a primary prevention population, finding a decreased incidence of heart attacks and coronary deaths. There are dozens of other studies now that purport to prove the same thing.

But a meta-analysis of four primary prevention studies, though finding a lower incidence of cardiovascular events and a lowered cholesterol, found no reduction in overall or cardiovascular mortality. In plain English, these drugs might affect how you die, but you die just as certainly, though with a lower cholesterol. And to even prevent one coronary event requires treating 60 people for five years, with a drug that costs over $1000/year. That is $300,000 to prevent one heart attack and not even save a life.

There are even more damning aspects to these studies, but you will have to wait for the movie. oops. I am no MM.

What is the bottom line? Statins do help prevent heart attacks and strokes, especially in the high-risk population, who have already had one event and want to prevent another. But even that attempt to prevent is lost in the host of other problems that plague mankind. This is the context that EBM misses. Even a relatively decent NNT falls into meaningless when considered amidst the myriad of medical, physical and routine risks of living. More on that when someone challenges me.

| By Robert Maddox | 04:32 PM

Comments

Interesting perspective - and perspective is what I am trying to establish since startingon Simvastin last January. I read so much about the negative side effects of statin drugs that I am considering doing without - overall c. number was 240. Any alternative medicines that you trust?

Posted by: marilyn cooley at July 9, 2007 05:44 PM

EBM? NNT?

Posted by: Gen at July 10, 2007 01:13 PM

Please remember that I am not giving medical advice. For all the problems of "standardized medicine" at least it has this over alternative medicine: we have measured the inefficacy of the former. EBM is that measure: Evidence-based Medicine. The old standard was the accumulated experience of my mentors, that was eventually codified in textbooks, or in GOBSAT (good ole' boys sitting around a table). One of the measurements most useful in the evidence is NNT, number needed to treat. How many must be treated to achieve the desired effect? Treat 60 people with the statin for five years and prevent one heart attack. NNH (harm) is the flipside.

Posted by: Robert at July 10, 2007 07:30 PM

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