Should Getting Old Be an Indication for Statin Therapy

unnamedI’ve been skeptical of the most recent American Heart Association and American College of Cardiology recommendations for statin use for prevention of coronary heart disease and stroke since they were released in Nov. 2013. Using the new calculator age over 60 for men or 70 for women, even with near prefect values for other risk components, usually leads to an AHA recommendation to consider statin therapy.  I am not alone in my reluctance to aggressively follow these recommendations.  The recommendations are a change from prior recommendations mostly in changing the threshold for 10 year risk of coronary heart disease and stroke from >10% o >5.0%.  This may sound minor, but because death from coronary heart disease remains the leading cause of death in older Americans this equates to a recommendation to treat nearly all older Americans with a statin.

I consider myself to be at a fairly low risk of coronary disease.  I’m 60 years old and male as my primary risk factors.  I do not have hypertension or diabetes, have never used tobacco, have pretty good lipid numbers, and exercise regularly. I’ve not had any prior known coronary disease.  The only family history of coronary disease was my Dad, a heavy smoker, having had a MI at age 69.

When I plug my numbers into the new AHA risk calculator:

 

Here are my numbers.

Age:  60

Ethnicity:  White

Systolic BP:  100-110, occasionally as high as 115 or as low as 95

Total Cholesterol:  `52

HDL Cholesterol:  50

Smoker:  No

Diabetes:  No

BP Medication:  No

When I plug this information into the AHA Cardiobascular Risk Calculator (click this link to calculate your risks or play with the numbers) the recommendation on whether I should start a moderate dose statin is dependent on which blood pressure measurement I use.  If I use my lowest systolic BP of 95 it projects a 10 year cardiovascular risk of 4.0% and recommends against statin use because my CV risk is less than 5%.  If I use the higher of my systolic BP measurements, a still very good 115 it calculates a 10 year CV risk of 5.6% and suggests use of a moderate strength statin medication like atorvastatin 10 mg, simvastatin 20-40 mg or pravastatin 40 – 80 mg daily.

The big problem with these recommendations is that the evidence for statin therapy for prevention of cardiovascular disease in patients with no diagnosed cardiovascular disease and relatively low cardiovascular risk of 5-10% is marginal at best. There is very strong evidence that statin use for prevention of another cardiovascular event in patients who have had one or more events already (secondary prevention) is highly beneficial. In primary prevention this evidence is far less convincing.  There is also controversy regarding whether the new calculator overestimates cardiovascular risk  because some of the data used to generate the calculator are from cohorts of patients over 2 decades ago when cardiovascular disease was considerably more prevalent.

Statin use is not without its risks. Muscle pain that can last months after stopping the drug is not rare.   The new AHA recommendations to treat nearly all men age 60 or older and most women over age 70, if adopted, will be a bold public health experiment. Check out this NY Times editorial published shortly after the guidelines were released.

I am a strong proponent of statin use in patients with prior cardiovascular disease, or in patients with diabetes, high LDL cholesterol or multiple risk factors making their risk for a heart attack or stroke quite high.  Bur for now I still try to base my recommendations regarding whether to advise statin use on overall cardiovascular risk using the AHA calculator and on their LDL cholesterol level.  I’ll continue to follow the experts opinions on this subject with much interest.

Leave a reply