Of life’s two certainties, death, and cataracts, it seems statins defer one and prompt the other, although not necessarily in the same person. If you blindly love life, you may be blinded by your love for life.
In the HOPE-3 trial, ethnically diverse people without cardiovascular disease were randomized to 10 mg of rosuvastatin daily and placebo. The treatment group had fewer primary events: death from myocardial infarction (MI), non-fatal myocardial infarctions, and non-fatal stroke. For roughly ten MIs averted there were seven excess cataracts. Peter may be blinded without being saved. Paul may be saved without being blinded. And then there is Rajeev, who may be blinded and saved. But the very nature of primary prevention is that you don’t know you’re Peter, Paul or Rajeev. So everyone is grateful to statins. Not even God of the Old Testament had such unconditional deference.
Once you’re taking statins, there is no way to disprove that any and every breath you draw is because of statins. Statins enjoy the metaphysical carapace, the immunity from falsification, which not even God enjoys. At least, you can experiment with God. Don’t pray for a week and see if you’re still alive- you know if God really cares about prayer-adherence. Even if you die at age 55 on statins, you can never disprove that you wouldn’t have died sooner if you weren’t taking statins.
HOPE-3 will have a different impact in different countries. In the U.S., it is a step closer to mixing statins with water. In some circles, statins have become proof of matrimonial commitment. I attended a birthday party of an Indian physician recently. It was a remorselessly boring event which was briefly animated by a discussion of what investments they were making. One physician said, looking at his wife dotingly, “My only investment is a statin. It keeps my wife safe.” His wife looked back at him lovingly in that LDL-induced hypnotic gaze.
It is the overburdened British GPs I feel sorry for. They will sink deeper into the rabbit hole of shared decision making. They will be obliged to yank people, who are well and minding their own business, from the streets and tell them in a non-judgmental tone: a) you may benefit from statins; b) there are no guarantees you will benefit from statins; c) you may develop a cataract; d) there are no guarantees you will develop a cataract; and, e) you may be blown up by ISIS, and all of this may be an utter waste of your time.
While some will use decision aids, flash cards, a clever app, the fact remains that GPs will be diverted from dealing with the presently ill to those who might be ill in twenty years. Primary prevention is like financial planning. GPs are expected to be like that professional who simultaneously manages bankruptcies and hedge funds.
HOPE is a Canadian-led politically correct trial funded by the Canadian Institutes of Health Research and AstraZeneca. Since Canadians are nicer people and are not motivated by money, we have been mercifully spared of protracted discussions of financial conflicts of interest (COI) with pharma. Obsession with COI just detracts from a fundamental truth, which is that there are many ways death can be marginally deferred probabilistically, which evidence-based medicine (EBM) will uncover.
If you still think EBM will reduce health care costs, you may as well believe in the tooth fairy. There are two legitimate reasons not to be on statins; you can’t be bothered to take them (which I suspect speaks for vast swathes of mankind), or the health care system can’t afford them. There is no shame in admitting the latter, but I suspect nobody will. But let us end the notion though that statins for primary prevention are unscientific.
The science of statins is an odd science, though. It is predicated on the numbers needed to treat (NNT). The NNT is a clever extension of absolute risk reduction, a bulwark against the therapeutic optimism of relative risk reduction. Some of Dr. Oz’s remedies have an NNT of infinity. A little shy of hundred, HOPE’s NNT is impressive. It might not have escaped your attention that “NNT-1” is the number who did not need to be treated.
The NNT conscripts a village to save an individual, but no one in the village knows who has been saved. Primary prevention is like winning a lottery every day but never seeing the money. Were I God, I’d be jealous of statins. Perhaps the statin is Vishnu’s tenth reincarnation.
Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad. This article originally appeared in the Health Care Blog.
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