Statins as primary prevention: Helpful or harmful?

A friend asked me recently about statins. He takes a statin for primary prevention but is concerned that he has muscle pain and weakness as a side effect. So he posed the question: “How important is the statin?”

The Washington Post had this recent article: “Who should take statins? A vicious debate over cholesterol drugs.”

But while nearly all experts agree that statins are beneficial for people at a substantial risk for heart disease, some medical researchers argue that statins do little or no good — and possible harm — for people at lower risk of heart disease. The conflict has burst into public view in the United Kingdom — and is likely heading here, too.

A bruising battle has played out for several years between Britain’s two leading medical research journals, the Lancet and the British Medical Journal (BMJ), which have accused each other of endangering public health. The debate has gotten so heated that it has made tabloid headlines (“STATIN WAR,” blasted the Daily Mail). It began when BMJ first questioned statins’ usefulness in 2014, publishing two articles that argued that the drug was being overprescribed to people with low risk of heart disease. It also claimed that the side effects from the drugs were worse than previously thought.

Statins have two major effects. First, they lower cholesterol levels. Lowering cholesterol likely decreases plaque size, therefore, patients will less likely have atherosclerotic complications. Second, they stabilize plaques, making plaque rupture and clot formation less likely.

In patients with known atherosclerotic disease (previous myocardial infarction, atherosclerotic stroke or symptomatic peripheral vascular disease), statins clearly decrease the probability of further events. Some patients with significant genetic predispositions and most patients with type II diabetes mellitus also fit into this secondary prevention category. For these patients, we really have no debate.

For the remaining patients, the debate becomes much more complex. Primary prevention in patients who do not fit into the previous paragraph has a minimal impact. Statins do decrease the risk of coronary artery disease, but the risk reduction is rather small. Statins, like almost all drugs, are not benign — they have side effects. The question, therefore, becomes the classic one — how does one balance the potential of the benefits and risks? (Or more simply put: Is the juice worth the squeeze?)

I explained this as best I could to my friend. I would not encourage statins for true primary prevention. Strong genetic predisposition and type 2 diabetes fit into a separate category. Statins help many patients and the benefits are strong as a secondary prevention medication. But the side effects are real and make the primary prevention question much more difficult. Currently, I do not favor primary prevention.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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