Should We Prescribe Cholesterol Lowering Medicines to People at Relatively Low Risk of Heart Disease?

Dr. Topol is one of the most respected physicians in the country.

And he believes that the risks of statins (cholesterol lowering drugs) when prescribed for persons without evidence of coronary artery disease (no history of previous heart attack) outweighs the benefits. (1)

He bases this belief on evidence that statins may increase the risk of diabetes in patients taking statins. He states “[That] in patients who have never had heart disease and are taking statins to lower their risk (so-called primary prevention), the reduction of heart attacks and other major events is only 2 per 100” and the risk of statins causing diabetes is one in 100.

Basically he is assuming that the number of lives saved by prevention of heart attacks in this group is outweighed by the number of live lost from the excess in diabetes in this group.

But he  has no data to support his view.

I believe, again based on no data, that the lives saved in this group from statins far exceeds any lives lost due to an increase in diabetes.

There is no data to support support either view.  It’s a blind bet.

There have been many examples of distinguished physicians making reasonable assumptions (without data) that later turned out to be completely wrong.

The test of cholesterol medicine and of all preventive medicines is: Does this medicine reduce all cause mortality in this group of patients? In higher risk patients the data is overwhelming: statins decrease all cause morality, meaning they save lives

The only way to tell if statins overall save lives in the lower risk group Dr. Topol  is talking about is to do a giant all cause mortality study. That is, for many years we treat half of a large group, maybe 50,000 people with statins for ten years and the then another 50,000 in the group we don’t treat with statins. We measure death from all causes in both groups.

It is important to measure the all cause mortality because only this measure captures all the risks and benefits, known and unknown, of a given treatment protocol.

We don’t have an all cause mortality study in this group of patients.

In the absence of an all cause mortality study in this group of patients (that is, patients without evidence of coronary artery disease who are at relatively low risk), all Dr. Topol (as well as doctors on the other side of the question) can do is guess.

(1) The Diabetes Dilemma for Statin Users. Eric Topol MD. Published March 4, 2012, New York Times.

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