Opinion:New AHA/ACC Statin Guidelines

Posted in Blog Health guidelines History of medicine Lifestyle Nutrition Perspectives Specific Health Conditions

I am greatly concerned by the new statin guidelines recently released by the American Heart Association and the American College of Cardiology during the yearly Scientific Sessions held in Dallas this November. Guidelines introduced to the public with great fanfare, and covered by all National media outlets. These guidelines take healthy people and input certain risk factors that include age, body weight, smoking history, family history of heart disease, blood pressure and cholesterol levels to determine future cardiovascular (CV) risk. Those that are found to have a CV risk of 7.5% or greater in the following 10 years would be candidates for statins. Statins were first introduced in 1987, and over the years their use has increased. Annual expenditure in 2000 on statins: $7.7 billion, by 2007: $20 billion. These medications help reduce the amount of cholesterol and LDL (so-called bad cholesterol) in the blood. It is believed however, that statins work to decrease heart disease because they reduce inflammation, an effect known as pleotropism.

Under the new guidelines, an additional 31 million people would meet criteria for these drugs. Currently, about 15% of all adults in the U.S. take statins and the new guidelines would double that number to around 33%. Generalizing treatment to a wide cross section is concerning because the likelihood of success or failure of a treatment is not identical in all individuals, and the therapy is not the only determinant of outcome.

It is this continued reliance and focus on drugs that concerns me. I am also confused by the frequent changes, recommendations and mixed messages made by the medical establishment. How often do we read a medical “expert” recommending one thing, only to have other “expert” recommend something completely opposite, contraindicating the first expert? In a country with so many “experts”, it’s no wonder why patients (myself included) don’t know who or what to believe.

Are we really so sure we should proceed to double the number of U.S. adults on statins, as suggested by the new guidelines? Can we be so sure that the benefits of this class of medicines outweigh the risks? We know that the use of statins in the short-term has adverse effects in some patients, but what happens after 10 or 20 years of use?

Cholesterol is not a villan. The absorption of vitamins and minerals including vitamin D, is dependant upon cholesterol, which is a reason our bodies produce it. Multiple studies have shown that statins users have higher rates of cataract formation, increase muscle pains, increased musculoskeletal injuries, reduced blood levels of vitamin D, and reduced levels of CoQ10, just to name a few. More importantly, statins may worsen and possibly cause diabetes. But in one of the ironies we have come to expect from modern medicine, the new AHA/ACC statin guidelines recommend statins for most diabetics.

I have nothing against statins. As a cardiologist, I prescribe statins when needed. What I am against is the indiscriminate use and abuse of not just statins, but of all medications and an ever-increasing reliance of medications for everything that ails us. I will continue to use statins in men younger than 75 years with coronary heart disease, including acute coronary syndrome, chest pain (angina), and those who have had heart surgery (bypass) or stents. People with hereditary hypercholesterolemia should also be considered for statin use. These are the groups that have been shown to get the most benefit from this class of drug. Their use in diabetic women and people with strokes (although current indications) is controversial.

Studies have shown that there is no reason or benefit for the elderly to be on long term statin treatment. Low cholesterol levels in people over the age of 75 have been associated with decreased cognitive function. Maybe this is because 25-30% of our brain is made up of cholesterol, and cholesterol is essential for many metabolic functions, including the production of hormones. However, there are even other medical “experts” who have suggested that it would be a good idea to start giving statins to children.

I find the reliance on medications that have potent side effects to be an ongoing failure of the U.S. healthcare system, the costliest healthcare system in the world that only manages a quality and efficiency ranking of 46, behind Iran and ahead of Serbia. It is time to end the “pill for every ill” mentally of disease care synonymous with U.S. health care and make a radical shift back to using common sense and reasoning.

Instead of prescribing more drugs, we should be educating and stressing to the general public the importance and need for lifestyle and nutritional change first. The same inflammation and conditions that cause the elevated cholesterol levels that are treated with statins, are caused by and therefore can also be limited and controlled by diet and improved nutrition. I find it interesting that the dietary advice of 40 years ago, which stressed the importance of eating minimally processed foods, avoidance of artificial sweeteners, selection of meats from organically raised animals and not industrially produced variety, went directly against the recommendations of the experts of that time.

I’ll continue to individualize treatment, educating my patients on the importance of food, exercise and lifestyle and prescribing drugs only when appropriate. I doubt future studies will find anything contradictory to this approach.

Jorge Bordenave MD FACP ABIHM
Coral Gables, FL       305-446-2444
Integrative Cardiologist
Assitant Clicinal Professsor of Medicine, Herbert Wertheim College of Medicine FIU
Cardiology Lecturer IM and FP Residency Program

The views expressed in the ABIHM Blog are those of the writer and do not necessarily reflect those of the ABIHM or its Directors.

2 Comments

  1. February 5, 2014 · 7:27 am | Permalink

    Dr. Bordenave,

    I am an internist/integrative doctor in Atlanta. I too am concerned on our over reliance on medication and particularly statins. I often question the validity of the evidence regarding the use of statins as primary prevention and maybe even some “high risk” pts. To my understanding, there are many trials that refute the efficacy of statin use for hard outcomes such as mortality and MI.
    1) The CORONA and GISSI-HF trials which placed pts with CHF on Statins with success in reduing LDL and CRP failed to show a survival benefit or decrease in coronary events
    2) The AURORA study and 4D trial evaluated pts on dialysis and again no difference in death CVA, cardiovascular death or nonfatal MI

    Many of the statin studies use LDL reduction as a proxy for cardiovascular disease/events and we now know this is incorrect logic. Cholestoral management is much more complicated than just LDL levels. As a result if studies did not evaluate hard endpoints such as reduced MI’s or mortality and only looked for outcomes such as LDL reduction, can we in good judgement allow those studies to guide our use of statins.

    I would love your thoughts

    Thanks

  2. 456jkl22
    February 10, 2014 · 10:36 pm | Permalink

    Response from Jorge Bordenave MD, FACP, ABIHM to Nicole Peoples, DO, ABIHM:
    Since the statin randomized controlled trials of 1990s, several reviews of the effects of statins have been published.

    A Cochrane Central review of 18 controlled satin trials with 19 trial arms (56,934 patients) from 1994 to 2008 compared statins with usual care or placebo. The mean age was 57 years, 60.3% were men, and 85.9 % were Caucasian. Duration of treatment was a minimum 1 year and with follow-up of a minimum of 6 months. All-cause mortality and fatal and non-fatal CVD events were reduced with the use of statins as was the need for revascularization. Of 1,000 people treated with a statin for five years, 18 would avoid a major CVD. As a cardiologist, statins in the right patient pop (post MI, CAD, PTCA, angina, familial hyperlipid) is the standard of care and I use it.

    AURORA study and 4D-examined statin benefit in pt w/ ESRD, a pop that does not currently meet guideline criteria for statin use.

    Both studies, found no significant CV benefit in pts w/ ESRD on HD.

    I agree strongly with you that control of cholesterol is much more than popping a pill. It’s a multifactorial issue of which diet, nutrition, stress relief, exercise all play a vital role. However, in the appropriately selected pt (younger than 75yo, MI, CAD, unstable angina, PTCA, CABG, fam hypercholesterolemia), they do play a role. At the very least, they reduce inflammation and helps stabilize plaque.

    Despite my being against the November recommendations from the AHA and ACC that increase statin use, they did limit statin treatment for those under age 75, and did not recommend statin for primary prevention in the elderly, which is great as this is a great concern to me. (This however did not sit well with some cardiologists who have written opinion pieces claiming they don’t understand why statins weren’t recommended in the elderly.)

    I see many physicians who may not understand the guidelines, who continuously RX statins to the elderly and to those with no CV history. This is costly, dangerous and plain wrong. I don’t know what logic is being used with so many conflicting comments and opinions.

    The American College of Endocrinology will not follow the AHA/ACC guidelines claiming a flawed methodology. Likewise, 5 weeks ago JNC-8 came out with new BP guidelines that raised the acceptable BP level to 150/90. Immediately after its release, 5 of the 14 members of the writing committee, each came out in opposition to the conclusions of the guidelines they had been a part of. This is part of the incorrect logic that has become acceptable in the business of medicine.

    “Garbage in, garbage out”. The truth doesn’t matter anymore.
    So much so, that I don’t know who or what to believe in as exemplified by the contradictions that surround both of the guidelines mentioned here.

    That fact that no physician or medical organization has spoken out against a writing / evaluation process that allows the publication of conflicting and controversial guidelines that lacks transparency and quality, is an indication of how broken medicine is.

    In conclusion, as a cardiologist, I recommend mid-dose statins for your CV patients as outlined above. No benefit from high dose. Use for the indicated time period and w/ lifestyle change. For older than 75, I am very cautious and hesitant.

    I believe the school of thought that low cholesterol has an inverse relationship w/ dementia. (Many published articles).

    Thanks, Nicole.

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