There is no free lunch–especially with statins

‘Good,’ I say.

Let’s spread the word that pills do not hold the answer to preventing heart disease. And while we are shouting, let’s add this one:

There’s no such thing as a free lunch!

Medicines come with more than just a dollar cost.

When an obscure AF doctor blogs about the limitations of statins for the primary prevention of heart disease, the sound barely rises to a whisper. Shhh, did you hear that?

But when a prominent professor of Cardiology and author, Dr Eric Topol, writes in the Sunday NYTimes that “we are overdosing on cholesterol-lowering statins,” the sound roars.

Dr Topol makes a compelling case against using statin drugs in low-risk patients who have yet to develop heart disease. He employs basic statistics to make the point that statin-induced diabetes might negate the drugs’ heart-protective effects. His emphasis of statin-induced diabetes applies both to the individual patient and the population as a whole. Most importantly, his thesis speaks to the important and increasingly-ignored story that medicines (and procedures) have risks.

I’d add three Mandrola caveats:

• Dr Topol’s point applies mostly to low-risk patients with isolated elevations of cholesterol. These patients enjoy such a low 10-year risk of heart disease that it’s hard to lower it any further. Remember, heart attack risk cannot go to zero.
• It should be re-iterated that when patients with heart disease benefit from statins. Compared to placebo, not exercise and lifestyle modifications, statins work well for secondary prevention.
• Many patients fall in between these two extremes. The moderate-risk patient with elevated cholesterol and another one or two risk factors (family history, high blood pressure, diabetes, smoking, obesity) presents a much tougher decision. It’s not so easy. These patients should have frank discussions with their doctor about the risks and benefits of statin drugs. It’s fair to say that the diabetes signal with statins warrants serious consideration.

My only regret about Dr Topol’s important proclamation was that he did not mention the critical role that exercise plays in lowering heart disease risk.

Think about it, how many patients considered for statin drugs have maximized their exercise and nutrition regimen? How many patients with peak fitness, low body-fat, good nutrition and regular sleep habits harbor many other cardiac risk factors? Why don’t doctors belabor the point that exercise-as-a-treatment strategy confers negative risk to the patient?

Just because exercise is a tougher pill to swallow than a statin doesn’t mean doctors should stop recommending it. It’s not mean to tell patients to exercise and lose weight; it’s good and safe medicine!

JMM