The debate over whether statins should be used for primary prevention moved to the Wall Street Journal with opposing perspectives from cardiologists Roger Blumenthal and Rita Redberg.
Blumenthal argues that “there is a mountain of high-quality scientific evidence” to support the use of statins in people without known heart disease but “demonstrated to be at high risk for heart disease.”
Redberg argues that “for most healthy people, data show that statins do not prevent heart disease, nor extend life or improve quality of life. And they come with considerable side effects. That’s why I don’t recommend giving statins to healthy people, even those with higher cholesterol.”
Both authors cite the West of Scotland Study and JUPITER in support of their position. Blumenthal concedes that long-term studies looking at mortality have not been performed, noting that such a study “would be enormously expensive and unwieldy, and take decades to complete.” Instead, Blumenthal cites evidence from meta-analyses, and the example of the wide acceptance of primary prevention for the treatment of high blood pressure, despite a similar lack of evidence.
Redberg says that the blood pressure data is more convincing than the statin data. No evidence supports a mortality benefit, she writes. The most “optimistic projections,” she writes, suggest that “for every 100 healthy people who take statins for five years, one or two will avoid a heart attack. One will develop diabetes.”
Both authors agree that diet and exercise are important. Blumenthal writes that “treatment doesn’t have to be all or none—all statin or all lifestyle. The two can be effectively combined to help our patients.” Blumenthal rejects the idea that statin are a moral hazard:
Think of it this way. If your doctor recommended a statin to you because of high risk of heart disease, would you eat more hamburgers because of this safety net or would you try to exercise a little more?”
Redberg believes statins take resources away from lifestyle changes:
If we were to spend a small fraction of the annual cost of statins on making fruits and vegetables and physical activity more accessible, the effect on heart disease, as well as high blood pressure, diabetes, cancer and overall life span, would be far greater than any benefit statins can produce.
Comment: I call it a draw. Redberg’s all-or-nothing attack on statins for primary prevention lacks nuance. Clearly this doesn’t need to be a binary decision. Statins are undoubtedly worthwhile for some people at high risk. The problem is identifying those people and deciding at what level of risk does statin use become reasonable. These are not trivial problems. Blumenthal, on the other hand, skates over the small reduction in absolute risk in primary prevention, citing the large relative risk reductions of statins on soft endpoints. He doesn’t state a clear way to identify a population in whom statins would be safe and cost effective.