Another take on the statin issue: Can lifestyle changes kill?

First a disclaimer: I’m a psychiatrist, not a cardiologist, but I’ve followed with personal interest the discussions about calculating cardiac risk and indications for statin treatment.  Risk is an interesting word, because risk is about populations; it loses the individual.

And it seems that statin treatment has taken on a bit of stigma — something we’re used to in psychiatry — now you can eat your cake and have low cholesterol, too!  The articles are all careful to point out that it’s preferable to lower cholesterol with lifestyle changes, that statins are for when such changes fail or for those who are too lazy and indulgent to even try exercise and dietary modification.

My brother did everything right.  His cholesterol was high when he was younger, and he worried a statin would have side effects, so he changed his diet.  He exercised regularly.   His HDL remained low, so he exercised more and his HDL rose.

At one office visit, he had mild hypertension, so he purchased a blood pressure cuff and recorded his blood pressure daily, confirming that the elevated reading had been an abberation.  As an economist, he loved data.  He had a negative stress test at age 50. He was never a smoker.   Last year, his blood sugar was elevated to 104, so even though he was not overweight,  he dropped down to what he weighed in high school. With lifestyle changes, my brother was able to manipulate his lab values, blood pressure, and weight, to avoid taking medications, and to achieve a low risk profile. He really did everything right, and as you can imagine, it was a shock when at age 59, in seemingly good health, he died of asymptomatic, severe calcified coronary artery disease. The only clue that such a thing could happen was that our father had died of a heart attack only hours after his initial presentation of chest pain while shoveling the snow at the age of 40, decades before statins existed.

At his last exam, my brother’s doctor had suggested he have a calcium score — my brother elected to hold off on this.  After all, he was feeling well and was exercising daily with no symptoms.  “Perhaps I should have insisted,” his doctor told me.

Calcium scoring improves risk prediction  in people without indications for statin therapy, according to a 2011 study in Atherosclerosis, “Coronary artery calcium score improves cardiovascular risk prediction in persons without indication for statin therapy.”

Still, the authors concluded, “… reclassification to the high risk category and overall event rates seem too low to justify liberal CAC  testing in all these individuals.”

Given that it my brother who died, I feel differently and I’m left to wonder if such screening might have saved my brother’s life.  Insurance companies, I’m now all too aware, don’t agree.  After his death, I had a 64 slice CT with calcium scoring. Aetna, my health insurer, later informed me that this exam is considered “experimental and investigational” in asymptomatic individuals, and as such it was not approved for coverage, even though the procedure required no pre-authorization and even though my genetics may be much different from the population that has been studied.

I’m not sure how a patient (me), the two physicians who recommended the test, the imaging facility that verified coverage, were supposed to know that Aetna would not agree with the clinical indication.

People die of heart disease with the most aggressive of interventions.  There are no guarantees and both the diagnostic procedures and the treatments come with their own risks.  The decision to recommend a statin or to perform a diagnostic test can be a life or death call, and issues of risk need to be considered in the context of the individual, not a population or an imperfect formula. Even in the best of worlds, the numbers plugged in to risk calculators — total cholesterol, HDL cholesterol, and systolic blood pressure — are labile and subject to change.  A person at high risk one day may be at lower risk another day.

The guidelines also place a strong emphasis on “patient preference,” when even the most educated of patients may not realize what is at stake — their life.  And patient preference is often guided by how strongly their physician emphasizes the risks versus the benefits; we think of these discussion as informed consent, but they often are more about sales technique.

And just to be clear, there’s more to coronary artery disease than self-discipline and lifestyle choices.  It may be that for some individuals, the focus on a healthy habits and optimal numbers becomes a distraction that moves us away from using more aggressive diagnostic and treatment options in people who might benefit from them.

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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  • Steven Park

    From what I’ve seen, whenever there is strong family history of heart disease or early death, there’s a good possibility that undiagnosed obstructive sleep apnea was involved. Sleep apnea significantly raises your risk of MI, stroke, and sudden death.

    We know now that even thin men and women who don’t snore can have significant apneas, despite relatively healthy BP readings and blood test levels. Furthermore, the patient is found to have severely narrowed upper airways from various degrees of craniofacial crowding, which prevent proper breathing and efficient sleep. This is why most people with these issues can’t sleep on their backs—there’s more obstructions and arousals due to tongue collapse.

  • Kristy Sokoloski

    Interesting article. Your brother’s age makes me think of what some others in the public are now asking about the death of actor James Gandolfini (not sure if I spelled that right) at the age of 51. However, what this also tells me is that sometimes even with the best of lifestyle choices people can still die from the various diseases that kill thousands every year. I think that even if a patient were to have the kind of testing such as you described with the calcium scores there’s still no guarantee that the life of a patient would be extended further. What this tells me is that there just is no simple answer and makes me wonder even further just how beneficial annual physicals and screening tests really are because regardless of our health status or family history we are all at risk for getting something serious.

    • Dinah

      Agreed, people get bad diseases and perhaps this was simply fate. But while there are “no guarantees,” why offer anyone bypass surgery/stenting or other interventions? And there is a lot of talk about how lifestyle changes can replace statins– there was one on KevinMD yesterday, perhaps the counterpoint to this article– but maybe my brother, or others in his situation– would have benefited from a statin in addition to his lifestyle changes, but his good numbers lured him into believing he was healthy, when in fact he was not? In the time since I submitted this article, my neighbor’s 57 year old father had a sudden cardiac death, it’s just not that uncommon. I think we need better methods to screen , and obviously the risk of screening asymptomatic people is that we then subject them to the cost and risk of more invasive testing when many of them will not have disease.

      While I am all in favor of exercise and healthy diets (whatever that is this particularly moment), the reality is that people have gotten big, they exercise less, and they live longer. Fewer people smoke and many take medications that were not available just a few decades ago.

    • buzzkillerjsmith

      I used to work with a good old doc who, after he did a physical and pronounced the pt fit, would say, “The guarantee extends to the clinic door.”

      • Kristy Sokoloski

        Meaning that the rest is up to the person that has seen the doctor. Yep, so true.

  • saurabh jha

    I am sorry to hear about your loss.
    In hindsight, calcium scoring CT might indeed have led to aggressive management of atherosclerosis that would have saved your brother’s life.
    But if the conclusions are to be drawn they must apply to all people with normal biochemistry and healthy lifestyle. All must have calcium scoring CT. Yes, there would be a life saved. But there would also be a life taken from complications of coronary angiogram or biopsy of an incidental finding, neither of which were destined to kill.
    The problem is we don’t know who will benefit and who will be harmed.

    • Dinah

      Maybe we could learn? Family history was not part of the Framingham risk calculations, it may be that people with certain risk factors are not “all people.”

      • saurabh jha

        You would have to study many people with those certain risk factors that you think are important, prospectively to see harms vs benefits of screening with calcium CT.

  • buzzkillerjsmith

    “…even though my genetics may be much different from the population that has been studied. ”

    This is the crux of your insightful post. We all know, implicitly and explicitly, that disease prevalence and hence screening recommendations differ by population. The problem here is that what is known is only a subset of what is true. It will always be that way.

    Sorry about your brother.

  • querywoman

    So many unknowns but we all die. Heart disease was found in man frozen in the Alps about 5000 years ago.
    Your brother’s body might have actually needed a different type of diet .Maybe he was deprived from what he needed to be.
    Weight loss is stressful. The medicine, Victoza, brought positive changes in my life, but I lost 26 pounds in the first two months and landed in the hospital with serious pneumonia for eight days.
    Two prior attempts to intentionally lose weight had left me with constant sinusitis, ear infections, and other URIs, and I had regained all the weight.
    I was even wondering why I was not sick with the Victoza and the weight loss and then I suddenly got ill.
    It’s been over a year now, and my doctors and I agree that the weight loss might have weakened my system, but I seem to have adjusted quite well to it no.

  • Carolyn Thomas

    My condolences on your brother’s untimely death, Dr. Miller. I suspect you didn’t write the headline for this post, however – which is an unfortunate one. Your brother’s “lifestyle changes” were in all likelihood NOT what killed him at all.

    His tragic story reminded me of Jim Fixx, the famous American journalist-turned-fitness guru, credited with launching the first big running boom back in the early 1970s. When Jim Fixx was 52 years old, he dropped dead while out on a 7-kilometre run. But he had a strong family history of heart disease. His own father had died of cardiac arrest at the age of 43.

    An autopsy showed Fixx had severe coronary artery disease with major blockages in three arteries. In reality, his very high level of fitness had likely helped to give him an extra decade of life compared to every other male relative. As in your brother’s case, this very strong family history alone could have led to his death decades earlier.

    Like Fixx, I was a healthy distance runner for decades – right up until I survived what doctors call the “widowmaker” heart attack five years ago. I was the most surprised person in the CCU while recuperating from the shock of first this diagnosis, and then the reality that I had survived what many do not. We can’t know for sure, of course, but my cardiologist theorized at the time that it was my running experience that may have saved my life by creating enhanced collateral arteries in the heart that help to ‘bypass’ coronary artery blockages – and those little collaterals may have even helped to postpone my cardiac event far longer than it was destined by fate to strike.

    What I’ve learned in my new life as a heart patient is that there are simply no guarantees about who will or will not be stricken. There is, sadly, no “Fair Fairy” when it comes to heart disease.

  • Wendy Belgard Hanawalt

    What this column and the responses to it say to me is that we are totally unwilling to accept the randomness, the uncontrollable nature of life. There is only so much that we can do. Your brother did everything “right” and he died. While I feel deeply for your loss, I also know that we are not given any guarantees. You can do everything “right” and still die; no one was promised otherwise. I remember back to a psychology class when one of the students was bemoaning the “unfairness” of life. The professor looked at him and said, “Life is infinitely fair. The only thing that you are promised when you are born is that you will die. On that, life has always kept its word.” This demanding that medicine MUST find the cure for everything is delusion, keeping us from recognizing that we’re here for a brief time and our longevity is not promised.

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