April 8, 2015
Statins: When Do Patients Without Existing Heart
Disease Need Them

Baltimore—While prescribing statins is routine for patients with a history of heart attacks and strokes, the issue isn’t as straightforward with the millions of U.S. patients who have high cholesterol but no obvious disease.

A new report from preventive cardiologists, led by Johns Hopkins University School of Medicine experts, provides some guidance to help patients and prescribers make the decision on treatment with statins.

The article, published recently in the Journal of the American College of Cardiology, looks at previously published research on the benefits and risks of long-term statin use.

“Given that heart disease tops mortality charts as the number one-killer of Americans, 'to statin or not to statin' is one of the most important questions faced by patients and physicians alike,” noted lead author Seth Martin, MD, MHS, an assistant professor of cardiology at the Johns Hopkins University School of Medicine and the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. “Our report offers concrete tips for clinicians on how to conduct this vital discussion and to reduce patient uncertainty and frustration in making this complicated decision.”

While side effects are infrequent and less common than future cardiovascular events in patients with established heart disease or stroke history, the risk-benefit balance is not as clear-cut among patients with high cholesterol and other factors that put them at likely—but not certain—risk for those problems, according to the article.

The latest guidelines from the American Heart Association and the American College of Cardiology recommend “considering” preventive therapy in those whose 10-year risk score for suffering a heart attack or stroke is 7.5% or higher.

“That decision should be informed by the intersection of scientific evidence, clinical judgment and patient preference, but clinicians need to individualize the advice,” explained study author Neil J. Stone, MD, Bonow Professor of Medicine/Cardiology at Northwestern University’s Feinberg School of Medicine.

The article offers the following tips that physicians and other healthcare professionals can use for helping patients make a decision about going on a statin:

• Don’t use the risk score as a shortcut to expedite decisions but as a conversation starter, particularly in light of recent findings that calculators used to determine the score tend to overestimate risk. Additional testing might be helpful in making the decision.
• Take the time to discuss the pros and cons of statin treatment even if the conversation extends over a period of time—or over multiple office visits for physicians.
• Contextualize the risk by comparing a patient's likelihood of suffering a heart attack or stroke to someone of the same age, gender and race with optimal risk factors while emphasizing that risk scores aren’t perfect predictors.
• Caution about the five Ms of statin use: memory, metabolism, muscle, medication interaction, and major organ effects. Discuss those risks versus benefits.
• Explain that statin use has been linked to a higher risk of developing diabetes and that the cholesterol-lowering drugs can hasten the onset of diabetes in those predisposed to it. Also point out that those who develop diabetes after starting statin therapy receive the same or even greater benefits in terms of reducing their cardiovascular risk.

The article also urges healthcare professionals to pay attention to news coverage about statins and heart disease. “News stories can and do shape patient perceptions of risk," Martin pointed out. “Understanding what messages patients are exposed to can give physicians valuable insights about their main concerns and worst fears, and it help them address these head on.”
U.S. Pharmacist Social Connect