Dispatch From The Wild Frontier Of The Statin Wars

First published on Cardiobrief.org

The long simmering controversy over the relative benefits and harms of statins has heated to a high boil with the release of the new AHA/ACC US guidelines. But nowhere is the battle more intense right now than in Australia where, according to the National Heart Foundation, a TV show may be the cause of 2,000 heart attacks and strokes over the next five years.

The program, wrote Amy Corderoy, the health editor of the Sydney Morning Herald, “claimed the causal link between saturated fat, cholesterol and heart disease was ‘the biggest myth in medical history’… [and described statins] as toxic and potentially deadly.”

"Catalyst delved into a raging debate: has dietary guidance telling us to avoid fats pushed us towards more harmful sugar and carbohydrates instead?

But the program also went a step further, arguing cholesterol was just an innocent bystander in the body’s attempts to deal with the sugar-damage. It was not a big leap to claim statins were dangerous, and the research supporting them fraudulent.

Catalyst focused heavily on the opinions of US experts – one of whom believes vaccines can cause autism and another who promotes chiropractic and chelation for heart problems – while downplaying the conclusions of other expert groups."

The program contained numerous quotes from cardiologist Rita Redberg, who has been a leading critic of statin overuse, especially when used for primary prevention. Redberg made clear that statins may be valuable for some patients who already have heart disease. But her views were accompanied by “experts” who were much more removed from the mainstream, including lengthy appearances, with little or no counterbalance, from extreme cholesterol skeptics like Beatrice Golomb and Stephen Sinatra.

The show initially came in for criticism from the Australian National Heart Foundation. Now the Heart Foundation reports that “an alarming number of people with high cholesterol have stopped or changed their cholesterol medication as a direct result of” the program. The Heart Foundation surveyed more than a thousand Australians receiving statins and recorded alarming findings:

• 22% stopped, stopped then restarted, or reduced their medications.
• 12% “started taking natural remedies.”
• 9% completely stopped taking their medication.

“Almost half of those who completely stopped their medications didn’t consult their GP,” said the CEO of the Heart Foundation. “What is most worrying is that of the people who have stopped taking their medication, one in four have previously had a heart event, such as a heart attack or stroke…. It should be clear that statins are life saving for people who have already had a heart attack, and people should not go off their medication without seeing their GP.”

Extrapolating from the survey findings, the Heart Foundation calculated that as many as 55,000 Australians may “have stopped their medication as a direct result of the show.” Of these, about 40% had either had a heart attack, a stroke, established heart disease, or had multiple risk factors for heart disease.

The Heart Foundation said that the estimate of 2,000 or more additional heart attacks and strokes was “a very conservative estimate.”

Statins For Primary Prevention Get A Boost

On the heels of the news from Australia, a comprehensive review in JAMAlends strong support to the use of statins in primary prevention. The review by Fiona Taylor and colleagues concluded that

"When used for primary prevention, statins are associated with lower rates of all-cause mortality, major vascular events, and revascularizations compared with placebo. Statin therapy is not associated with increased rates of life-threatening adverse effects such as cancer."

Here are the relative risks, 95% confidence intervals, and the number need to treat for 5 years:

• All-cause mortality: RR 0.86, CI 0.79- 0.94, NNT 138
• Combined fatal and nonfatal CVD RR 0.75, CI 0.70-0.81, NNT 49
• Combined fatal and nonfatal coronary heart disease (CHD) events: RR 0.73, CI 0.67-0.80, NNT 88
• Combined fatal and nonfatal stroke: RR 0.78, CI 0.68-0.89, NNT 155

In an accompanying editorial, Jennifer Robinson writes that

“the accumulated evidence should convince those with a philosophical aversion to statin therapy for primary prevention to reconsider their stance.”

In a viewpoint published earlier this month in JAMA, John Ioannidis discussed the implications of the new guidelines and the expanded population now eligible for statins that

“eventually would lead to massive use of statins at the population level; ie, ‘statinization’. It is uncertain whether this would be one of the greatest achievements or one of the worst disasters of medical history.”