Are You On The Fence About Taking a Statin Drug?

How a more personalized risk estimate can inform the doctor-patient decision

I wrote a post in 2017 that personalized the decision that the vast majority of American men in their 60s and women in their 70s will be asked to make: whether or not to take a statin.

The 61 year old subject of that post started on a statin and has done extremely well. His lipid values have improved substantially, he has had no cardiovascular events, and he is rowing daily at a high intensity without any problems. Of note, he has had no side effects from the medication.

I am updating this piece in hopes that it will provide guidance for those individuals in their 60s with borderline lipid levels on making the right decisions on cholesterol-lowering therapy.

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The father of the eternal fiancee' of the skeptical cardiologist (FOEFOSC, let's call him "Geo") is a typical 61-year-old white male. A year ago his primary care physician informed him that he needed to start taking a statin drug because his cholesterol was high.

The note accompanying this recommendation also stated "work harder on diet and exercise to get LDL<130."  No particulars on how to change his current diet and exercise program were provided.

Neither of Geo's parents and none of his siblings have had heart problems at an early age and Geo is very active without any symptoms. His diet is reasonably free of processed food and added sugar, he is not overweight and his blood pressures are fine.

Due to concern about side effects he had read about on the internet and because he doesn't like taking medications, Geo balked at taking the recommended statin.

Reluctance to start a new and likely life-long drug is understandable especially when combined with a constant stream of internet-based bashing of statins.

Tools to More Precisely Determine Personal Risk

My advice was sought and I suggested a few things that would be helpful in making a more informed decision:

-Calculate Geo's 10-year risk of heart attack and stroke using the ACC ASCVD Risk estimator which utilizes the standard risk factors including age, gender, BP and lipid levels. Guidelines recommend the ACC/AHA ASCVD risk estimator tool (app available here) as the starting point for estimating an individual's risk. If 10 year risk is >7.5% then statin therapy is warranted to lower the risk.

-Assess for the early or advanced build-up of atherosclerotic or fatty plaque in the coronary arteries (coronary calcium scan or CAC).

As I've pointed out before (here), the majority of men over the age of 60 move into a 10-year risk category >7.5%, no matter how great their lifestyle is, and Geo was no exception with a risk of 8.4%. His total cholesterol was 249, LDL (bad) 154, HDL (good) 72 and triglycerides 116.

Geo underwent the CACs at a local facility and his coronary calcium score came back at 18,  putting him at the 63rd  percentile. This is slightly higher than average white men his age.

If I have information on my patient's CAC score I use a superior ASCVD risk estimating tool called the MESA risk score calculator. It is available online and through an app for Apple and Android (search in the app store on "MESA Risk Score" for the (free) download.) I describe in detail how to utilize it here.

The MESA tool allows you to easily calculate how the CACS affects you or your patient's 10-year risk of heart attack or stroke (aka ASCVD.) Using MESA clinical input plus CAC has been shown to be superior at predicting ASCVD risk in all risk categories to the AHA/ACC ASCVD risk estimator (see here.)

A More Precise Risk Estimate

Since Geo's CAC score was not far from average for his age and gender his overall risk estimate was not changed substantially.

What we had learned is that he was not free of atherosclerotic disease. It had begun forming in his coronary arteries. We were confident he was at intermediate risk for heart attack and stroke over the next 10 years.

In a separate post I have described how in another man facing the same decision we obtained a CAC with a zero score. That man had no atherosclerosis and we could confidently recommend no statin treatment. The zero CAC score in men over age 60 is a powerful predictor that cardiovascular events are unlikely. Statins can be deprescribed once such individuals are derisked. Studies have shown that utilizing CAC reduces overall prescription of statins but enhances adherence to taking statin when it is prescribed.

On the other hand, I have many cases in which we have identified markedly elevated CAC scores, above the 75th percentile for age and gender. While some doctors poopoo the value of the CAC, in these asymptomatic patients, identifying and treating early subclinical atherosclosis can be life-saving.

Engaging in Shared Decision Making

When Geo presented these findings to his PCP, the doctor seemed unaware of the ASCVD risk estimator (recommended by AHA/ACC guidelines first published in 2013). His PCP also seemed miffed that he had gotten the coronary calcium scan. Geo felt like the PCP's attitude was "shut up and do what I tell you."

Geo's PCP's approach exemplifies a not-uncommon traditional doctor-patient relationship, but a better approach is shared decision-making (see here). Geo, like many patients, welcomes more information on the risks and benefits of any recommended treatment so that he can participate in deciding the best course of action.

I steer patients who want more complete information towards my  evidence-based blog posts on statins (see here for a discussion on statin side effects and here for statin benefits beyond cholesterol lowering.)

By giving patients more information on the risks, side effects, and benefits of the statin drugs along with a better understanding of their overall risk of heart disease and stroke, we can hopefully move more patients “off the fence” and onto the most appropriate treatment.

You can read about the compromise approach we worked out for Geo here. Like many individuals, Geo was exposed to negative articles about statins and stopped taking them. Read more about what happened with Geo here.

Decisively Yours
-ACP

N.B. When I wrote this post in 2017 I was also utilizing ultrasound examination of the carotid arteries (vascular ultrasound) to assess ASCVD risk. I had developed a high quality vascular screening lab at my hospital. A vascular ultrasound showed below-normal carotid thickness and no plaque. This approach is helpful if you have access to a high quality facility performing carotid IMT/carotid plaque identification and the CAC score is zero in a man under the age of 50 or a woman under the age of 60.

N.B.2 For more discussion on the value of coronary artery calcification (CAC) and the value of statin in lower-risk patients see this recent paper entitled "Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions"(PDF refining-statin-prescribing-in-lower-risk-individuals-informing-riskbenefit-decisions)

Since writing this post I have added articles on statins and memory loss and the importance of the nocebo effect in patients taking statins.