The Ongoing Statin Debate, or Is It?

Those of you who are heartily sick of my talking about statins, please skip this post.

By way of joining in on the controversial new statin guidelines:
http://brodyhooked.blogspot.com/2013/11/new-cholesterol-guidelinesthe-devil-in.html
--the New England Journal offered in their April 24 issue a debate over the guideline recommendations. Three authors were assigned to take positions on a hypothetical 52-year-old male smoker with a normal cholesterol and LDL level (subscription required):

• Do not treat with statins: Dr. Benjamin J. Ansell
• Treat with statins and monitor LDL levels: Dr. Samia Mora
• Treat with statins but do not monitor LDL: Dr. Harlan M. Krumholz

OK, so this sounds at first like one person taking the position I have argued for in this blog, and two others taking positions more favorable to the drug manufacturers. But things may not be quite as they seem.

Dr. Ansell does indeed argue against statins, using arguments we've reviewed previously, and noting the much bigger bang for the buck with lifestyle interventions, notably smoking cessation. But Drs. Mora and Krumholz don't dispute the importance of lifestyle--indeed you could say that we have here three arguments, all in favor of pushing lifestyle modification as the first step.

Dr. Mora makes out his favorable case for statin treatment and monitoring LDL by selecting some studies that seem to him to support this approach, but his concern seems to be that by closely watching LDL levels, the physician might find a low dose of statin that reduces risk sufficiently while avoiding the potential adverse effects of statins. So at least one of the "statin advocates" in this debate admits that statins can be harmful and should be used in lowest possible doses.

Dr. Krumholz is not really advocating for statins at all, it seems, but rather for patient choice and shared decision-making. And what information would he give the patient for this purpose? He'd stress that 50-60 people like this patient would have to be treated with statins for 10 years for a single one of them to avoid having a heart attack. He says that if he told the patient this, and the patient still wanted to take statins, he'd prescribe them--certainly a reasonable choice in my view.

In short, even the debaters that supposedly take the pro-statin positions in this "debate" actually have more negative things to say about statin therapy than the title would suggest.

D'Agostino RB, Ansell BJ, Mora S, Krumholz HM. The guidelines battle on starting statins (clinical decisions). New England Journal of Medicine 370:1652-1658, April 24, 2014.