As you may recall, in a previous video I addressed the topic of statin drugs, and whether these drugs are over-prescribed.  In that video, I criticized the approach of treating people’s cholesterol without any regard to the patient’s cardiovascular health or to other considerations.

Recently, Dr. Steve Nissen, chairman of cardiovascular medicine at the famed Cleveland Clinic and a very vocal proponent of statins, wrote an editorial in which he rebukes those who question the use of statins as “an internet-driven cult with deadly consequences,” a cult he calls “statin denial.”

Those are pretty strong words.  In fact, I think these are smearing words, meant to stifle any debate.

Am I a statin-denialist?  I’m not sure.  Dr. Nissen defines the problem as he sees it in 2 ways:  1) statin denial is “the proposition that cholesterol is not related to heart disease” and 2) statin fear is the notion that lowering serum cholesterol levels will cause serious adverse effects, such as muscle or hepatic toxicity—or even worse, dementia.”

Now, it’s true that some people hold an extreme position regarding statin drugs and, in my opinion, exaggerate their risk.  But it is undeniable that thousands, if not millions of healthy people are prescribed statin drugs—and therefore turned into patients, who need to worry and undergo constant monitoring.  The risk of being healthy yet turned into a patient is, in my opinion, very serious.

It is also true that cholesterol is very imperfectly correlated with heart disease.  It cannot be said to “cause” heart disease with any degree of certainty.  In fact, the predictive value of the cholesterol level by itself is really marginal, and there are many well-credentialed doctors who disagree with Dr. Nissen and who could hardly be classified as fringe “cultists.”

Nissen also ridicules patients and doctors who seek to manage cardiovascular disease and cardiovascular risk with dietary changes.  Although the question of dietary intervention is a very complex one, I think it is wrong to pass judgment on patients making personal choices about how to care for themselves.

In the last few months, there’s been a very strong back-and-forth in medical journals between academics in favor of, and academics cautious against the use of statins.  I have called it the statin war. The problem with this war is that each side tries to make its case on a utilitarian basis.  Each side examines data from large studies that show that x percent of patients have this or that benefit, and y percent of patients have this or that side effect.  And each side then tries to “compute” a recommendation that applies to everybody.

As I explained before, my point of view is that the decision to use a statin should always be made on a case by case basis.  Every person is different, and there are many personal factors that must be taken into consideration.  Treating patients “by the numbers” is likely to lead both to overuse and underuse statins.  Instead, the decision should be guided by whether or not there is evidence that the patient has any detectable abnormalities with the heart or the arteries, and by other considerations specific to the patient.

Another problem is that much of the debate regarding statins is marred by conflicts of interest.  On the one side, Big Pharma funds a lot of doctors, including Dr. Nissen, and also funds many medical journals through advertising.  On the opposite side, health policy experts who receive government grants seem to want to find any possible reason to ration care.  Some of these experts are ideologically driven and systematically downplay any benefit of treatment, including any potential benefit of statins.

The only way to get past this unhealthy debate is for doctors to take the time to understand their patients’ needs and personal circumstances, so that trust can be established and patients can feel that their best interests are taken into consideration.

There shouldn’t be a pro-statin or anti-statin debate, and certainly no smearing of personal medical decisions as “denialism.”  There should be a pro-patient position of doing the right thing, one person at a time.

— Dr. Accad

Update: A related blog post from the Lown Institute Is There a Middle Ground in the Statin Debate?

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