I just realized that I had written "I did intend to bash PCPs" when I mean I did not. Fortunately, I think the context of the sentence makes it clear I meant not but it is now corrected.
Similar to you, my eldest daughter excelled in med school and chose primary care. Great primary care doctors like you and her are essential to quality health care but they are in short supply and at greater risk of burn-out due to many factors.
Hi. The PCP not knowing about ASCVD risk calculators would be a red flag against that clinician. Be careful with general PCP bashing though, as our role cannot be a luxurious deep dive into the nuances of each problem and medical decision. Most patients will not read through 5 articles you have constructed to help them, but they will read 5 articles that induce statin fear and undermine your expertise.
The doc who said “work harder on diet and exercise to get LDL<130” then probably went on to coordinate 10 other problems including a review of specialist letters, imaging studies, chronic medical problems like diabetes, cancer surveillance, htn, a recent hospitalization, anxiety and depression, OSA, etc. I think we all know from constant bombardment what “work harder on diet” means... don’t eat crap, eat more vegetables and healthy proteins and fats... and if the patient doesn’t, then suggesting a nutritionist consultation (which usually takes a whole hour we don’t have) or picking up a book on Mediterranean style diet would be a good idea for the truly motivated patient. The ones who’ve made it to see a cardiologist for primary prevention are already a highly engaged, educated, and motivated population unlike the baseline primary care population, many of whom are underinsured and can’t really afford CAC. I know it’s hard to imagine, but it’s true.
I recall an article about CAC testing and pitfalls published by the AAFP and written by John Mandrola. As family docs we really do depend on consensus guidelines- if we got tangled in the nuanced weeds of every decision we would need AI and 27 more hours per day (the amount of time already estimated a family doc would need to take care of everything that has been advised of them in patient care!). So we follow guidelines, and there is safety in that.
And the most frustrating thing about ASCVD calculators is that they do not include family history! Isn’t that one of the foundational risks?! Please let me know if there is such a calculator, assuming it’s been validated, so I don’t end up sounding ignorant like the PCP you’ve mentioned. Nonetheless, cut the rest of us some slack please 😉
I am a former patient of Dr P. My cholesterol was predictably high and was put on avoristatin (I think by my PCP at the time). I immediately had a severe reaction to the medication. I struggled to walk as my muscles were completely bound up. My pharmacist told me I was one of 5% to have this severe of a reaction and stop it immediately. After blood tests my muscle enzymes count was 3 times above normal. It took over a year for them to fall to normal range and pain to dissipate. Thankfully Dr P prescribed Praulent shots which works great and I tolerate very well. I for one will NEVER take ANY statin for ANY reason. Dr P also introduced me to the Kardia App which I use to this day to self monitor and for which I am very grateful!! Thanks for the chance to comment.
Just using the tools you referred to, take your analysis one step further for your putative FIL and you get to the numbers that color in the hesitancy on statins. If you assume a 50% reduction in total cholesterol and no change in HDL cholesterol with the statin, the MESA risk calculator generates a 10-year risk of 3.4%, compared to 4.6% baseline. The ACC/AHA calculator won’t give a 10-year risk for LDL cholesterol under 70.
OK, that’s nice, a 1% reduction in 10-year risk. But 99 people out of 100 take 3,650 pills, one every morning for 3650 days, and get no benefit. Geo’s chances are 99 in 100 that he’ll be one of those who get no benefit.
The insurance companies save a lot of money for sure. The data reveals a mortality reduction. But the benefit for each individual with this risk profile is pretty scanty.
Interesting post. My particular case was that with high cholesterol in my 50s, I was not prescribed statins due to a similar risk analysis matrix. While a grandfather had died of a heart attack in his 50s, my parents both succumbed to cancer quite young, so there was little info on their cardiovascular health in older age. I would be asked if my grandfather had high cholesterol. He died in 1955, before I was born and before such measurements were common (AFAIK). So who knows?
My cholesterol level was high enough that my optometrist noticed it during an eye exam. But my medical check-ups still resulted in recommendations to eat less fatty food and drink less and no statins.
By fortunate accident, I was visiting South Africa and needed some malaria prophylactics. I visited a doctor I knew, and he did a sort of wellness check where we decided to check my PSA level and a few other labs. The PSA was fine, but he was worried about my cholesterol level.
I had read (damn you Internet!) about a more-accurate test for lipids called ApoB, so I asked to have it as well. It was sky-high - much higher than my HDL/LDL levels would have implied.
I managed to get an appointment with a local cardiologist, whose opening line was "How are you still alive?" That gets your attention. He asked about my ancestry, which is Huguenot French. Many of the Huguenot also went to South Africa, and there is a genetic condition (Familial Hypercholesterolemia) common in those families, which I also appear to suffer from.
An ECG and stress test were normal (but I could be in better fitness - weight is fine). However an ultrasound showed 30% blockage in one carotid artery. I started on statins and a low-carb diet and my ApoB levels went from literally off-the-chart to extremely low. That was five years ago and subsequent ultrasound shows a reduction and smoothing of the visible plaque.
If I had not had a chat with a helpful GP and then asked for the ApoB test, plus chosen a cardiologist familiar with FH, I probably wouldn't be here to write this.
We should stop talking LDL, HDL, VLDL, Triglycerides. What matters is MI , Mortality and overall health. And no talk about relative risk. Some of the landmark studies had statistics done by the drug companies that were pushing their statin. These drugs can cause permanent muscle damage.
I'm 74. Woman. Had a heart attack 4 years ago. Two stents put in I only took statins 1 month. Blood thinner 6 months. I take 4 to 6 grams Vitamin C/day plus a few other things (Linus Pauling protocol). Four months after the heart attack had eco test, cardiologist report "Dramatic improvement". Besides I feel great no problems. No meds.
I'm in that curious component of the statin-intolerant. I've read the literature and assessed the quality of the studies (some early studies were rather poorly designed and the outcomes seemed predetermined). I've tried low-dose simvastatin and low-dose, alternating day atorvastatin.
Simvastatin did, according to my wife, induce a loss of short-term memory, and loss of attention to detail. Between her demand, and my significant myalgia (which resolved in 2 weeks after discontinuation) I managed 3 months of therapy.
Atorvatstatin was really worse. Fasting sugars popped up into the 200's from less than 110. myalgia was absolutely intolerable: I became an ibuprofen addict with acetaminophen as a kicker. This likely caused mood changes noted, again, by my wife. I couldn't concentrate on work-related issues.
Note that my 10 yr risk is about 13%, with T2DM, mild HTN, and excellent selection of grandparents with regard to lipids. Aside from the claims by lipidologists that they'd love to lower LDL to zero (mine's 75) I don't have much room to move on "fixing" my lipid status.
One concern I have with statins is I'm not exactly sure of the mechanism of action. We have studies that claim improvements in all-cause mortality, but if this is solely from lowering LDL, that claim's a little loose, at least to my way of thinking.
A generally excellent piece by ACP: However, it was not stressed strongly enough the 95% of elevated cholesterol (goal nonHDL cholesterol of 90 or less and triglycerices of 100 or less) is completely curable by a combination of diet and exercise. I did not say this was easy, convenient, or as comfortable as what people are used to. It is a simple statement of fact that some will grasp and act on. Here is my recent publication on that very subject :'Medical Research Archives 'January, 2023: "The Unhappening of Heart Disease."
I am not on the fence at all. I developed Auto Immune Hepatitis from the statins. I went on them and 6 months later almost needed a blood transfusion. LFT's were all over the place. He took me off statins. A month later LFT's almost back to normal and my blood count was almost normal. I personally think statins are over prescribed.
I just realized that I had written "I did intend to bash PCPs" when I mean I did not. Fortunately, I think the context of the sentence makes it clear I meant not but it is now corrected.
Ryan,
Similar to you, my eldest daughter excelled in med school and chose primary care. Great primary care doctors like you and her are essential to quality health care but they are in short supply and at greater risk of burn-out due to many factors.
Here's my post on the MESA app (https://theskepticalcardiologist.com/wp-admin/post.php?post=36905&action=edit&calypsoify=1)
It allows a calculation without the CAC score and it includes family history!
In the example I describe a 64 year old with a 175 score goes from 4.7% to 8% risk
Dr P
Hi. The PCP not knowing about ASCVD risk calculators would be a red flag against that clinician. Be careful with general PCP bashing though, as our role cannot be a luxurious deep dive into the nuances of each problem and medical decision. Most patients will not read through 5 articles you have constructed to help them, but they will read 5 articles that induce statin fear and undermine your expertise.
The doc who said “work harder on diet and exercise to get LDL<130” then probably went on to coordinate 10 other problems including a review of specialist letters, imaging studies, chronic medical problems like diabetes, cancer surveillance, htn, a recent hospitalization, anxiety and depression, OSA, etc. I think we all know from constant bombardment what “work harder on diet” means... don’t eat crap, eat more vegetables and healthy proteins and fats... and if the patient doesn’t, then suggesting a nutritionist consultation (which usually takes a whole hour we don’t have) or picking up a book on Mediterranean style diet would be a good idea for the truly motivated patient. The ones who’ve made it to see a cardiologist for primary prevention are already a highly engaged, educated, and motivated population unlike the baseline primary care population, many of whom are underinsured and can’t really afford CAC. I know it’s hard to imagine, but it’s true.
I recall an article about CAC testing and pitfalls published by the AAFP and written by John Mandrola. As family docs we really do depend on consensus guidelines- if we got tangled in the nuanced weeds of every decision we would need AI and 27 more hours per day (the amount of time already estimated a family doc would need to take care of everything that has been advised of them in patient care!). So we follow guidelines, and there is safety in that.
Here’s the counterpoint:
https://www.aafp.org/pubs/afp/issues/2019/1215/p734.html
And the most frustrating thing about ASCVD calculators is that they do not include family history! Isn’t that one of the foundational risks?! Please let me know if there is such a calculator, assuming it’s been validated, so I don’t end up sounding ignorant like the PCP you’ve mentioned. Nonetheless, cut the rest of us some slack please 😉
I am a former patient of Dr P. My cholesterol was predictably high and was put on avoristatin (I think by my PCP at the time). I immediately had a severe reaction to the medication. I struggled to walk as my muscles were completely bound up. My pharmacist told me I was one of 5% to have this severe of a reaction and stop it immediately. After blood tests my muscle enzymes count was 3 times above normal. It took over a year for them to fall to normal range and pain to dissipate. Thankfully Dr P prescribed Praulent shots which works great and I tolerate very well. I for one will NEVER take ANY statin for ANY reason. Dr P also introduced me to the Kardia App which I use to this day to self monitor and for which I am very grateful!! Thanks for the chance to comment.
Larry Scales
Despite our disagreements here and there, I still consider your insights and writings excellent
Gerry,
Fortunately, we have some great options for patients like you who are at high ASCVD risk but have significant intolerance to statins.
Ezetimibe has an excellent side effect profile and has shown improved outcomes.
The PCSK9 inhibitors are very effective with good outcome data and minimal side effects.
Yesterday, we heard at the ACC that bempedoic acid lower MAC in stat in-intolerant high risk patients.
All of these drugs, by the way, work by one method or another to lower apo B and LDL levels.
Dr. P
Skeptical,
Just using the tools you referred to, take your analysis one step further for your putative FIL and you get to the numbers that color in the hesitancy on statins. If you assume a 50% reduction in total cholesterol and no change in HDL cholesterol with the statin, the MESA risk calculator generates a 10-year risk of 3.4%, compared to 4.6% baseline. The ACC/AHA calculator won’t give a 10-year risk for LDL cholesterol under 70.
OK, that’s nice, a 1% reduction in 10-year risk. But 99 people out of 100 take 3,650 pills, one every morning for 3650 days, and get no benefit. Geo’s chances are 99 in 100 that he’ll be one of those who get no benefit.
The insurance companies save a lot of money for sure. The data reveals a mortality reduction. But the benefit for each individual with this risk profile is pretty scanty.
Interesting post. My particular case was that with high cholesterol in my 50s, I was not prescribed statins due to a similar risk analysis matrix. While a grandfather had died of a heart attack in his 50s, my parents both succumbed to cancer quite young, so there was little info on their cardiovascular health in older age. I would be asked if my grandfather had high cholesterol. He died in 1955, before I was born and before such measurements were common (AFAIK). So who knows?
My cholesterol level was high enough that my optometrist noticed it during an eye exam. But my medical check-ups still resulted in recommendations to eat less fatty food and drink less and no statins.
By fortunate accident, I was visiting South Africa and needed some malaria prophylactics. I visited a doctor I knew, and he did a sort of wellness check where we decided to check my PSA level and a few other labs. The PSA was fine, but he was worried about my cholesterol level.
I had read (damn you Internet!) about a more-accurate test for lipids called ApoB, so I asked to have it as well. It was sky-high - much higher than my HDL/LDL levels would have implied.
I managed to get an appointment with a local cardiologist, whose opening line was "How are you still alive?" That gets your attention. He asked about my ancestry, which is Huguenot French. Many of the Huguenot also went to South Africa, and there is a genetic condition (Familial Hypercholesterolemia) common in those families, which I also appear to suffer from.
An ECG and stress test were normal (but I could be in better fitness - weight is fine). However an ultrasound showed 30% blockage in one carotid artery. I started on statins and a low-carb diet and my ApoB levels went from literally off-the-chart to extremely low. That was five years ago and subsequent ultrasound shows a reduction and smoothing of the visible plaque.
If I had not had a chat with a helpful GP and then asked for the ApoB test, plus chosen a cardiologist familiar with FH, I probably wouldn't be here to write this.
We should stop talking LDL, HDL, VLDL, Triglycerides. What matters is MI , Mortality and overall health. And no talk about relative risk. Some of the landmark studies had statistics done by the drug companies that were pushing their statin. These drugs can cause permanent muscle damage.
I am a very skeptical retired Pharmacist.
I'm 74. Woman. Had a heart attack 4 years ago. Two stents put in I only took statins 1 month. Blood thinner 6 months. I take 4 to 6 grams Vitamin C/day plus a few other things (Linus Pauling protocol). Four months after the heart attack had eco test, cardiologist report "Dramatic improvement". Besides I feel great no problems. No meds.
I have been on a statin since A-Fib June 2018, Elequis also...numbers fine no side effects.
I am curious as to whether you have written any articles on statins for those of us 75 years old or older? If not, would you.
No I am not on the fence. I refuse.
I'm in that curious component of the statin-intolerant. I've read the literature and assessed the quality of the studies (some early studies were rather poorly designed and the outcomes seemed predetermined). I've tried low-dose simvastatin and low-dose, alternating day atorvastatin.
Simvastatin did, according to my wife, induce a loss of short-term memory, and loss of attention to detail. Between her demand, and my significant myalgia (which resolved in 2 weeks after discontinuation) I managed 3 months of therapy.
Atorvatstatin was really worse. Fasting sugars popped up into the 200's from less than 110. myalgia was absolutely intolerable: I became an ibuprofen addict with acetaminophen as a kicker. This likely caused mood changes noted, again, by my wife. I couldn't concentrate on work-related issues.
Note that my 10 yr risk is about 13%, with T2DM, mild HTN, and excellent selection of grandparents with regard to lipids. Aside from the claims by lipidologists that they'd love to lower LDL to zero (mine's 75) I don't have much room to move on "fixing" my lipid status.
One concern I have with statins is I'm not exactly sure of the mechanism of action. We have studies that claim improvements in all-cause mortality, but if this is solely from lowering LDL, that claim's a little loose, at least to my way of thinking.
Suggestions?
A generally excellent piece by ACP: However, it was not stressed strongly enough the 95% of elevated cholesterol (goal nonHDL cholesterol of 90 or less and triglycerices of 100 or less) is completely curable by a combination of diet and exercise. I did not say this was easy, convenient, or as comfortable as what people are used to. It is a simple statement of fact that some will grasp and act on. Here is my recent publication on that very subject :'Medical Research Archives 'January, 2023: "The Unhappening of Heart Disease."
I am not on the fence at all. I developed Auto Immune Hepatitis from the statins. I went on them and 6 months later almost needed a blood transfusion. LFT's were all over the place. He took me off statins. A month later LFT's almost back to normal and my blood count was almost normal. I personally think statins are over prescribed.