If you haven’t yet been asked to decide whether to take a statin to lower your cholesterol and cut your chance of a heart attack, you will be. According to the latest ‘evidence’, the decision is a no-brainer.
These drugs have been subject to dozens of large trials, which have found that on average they cut your chance by roughly 20 per cent. The latest big trial, reported in The Lancet, showed that they benefit you even if your risk of heart disease is low and, more importantly, they have no risk of serious side effects. So what’s not to like?
What most people don’t understand, quite reasonably, is that a drug trial is not designed to answer the question: should I take this drug? Instead, it tells you what happens, on average, in a fairly large group that takes them. So trials are useful for answering an administrative question such as: are statins cost effective?
If you know the average number of heart attacks or heart operations every year and what they cost, a big statin trial will tell you how many fewer you can expect by widespread prescribing. Then, knowing the cost of a statin, you can work out if they are a good deal.
So the latest Lancet paper may well be useful on Capitol Hill, but it’s not going to help you much when the doctor offers to write you a prescription.
So what should you do? The short answer is: don’t start them. If you haven’t had a heart attack, that is. And here are five reasons why not.
1. The statistics
If statins were in a horse race you wouldn’t even consider betting on them. The odds of benefitting are lousy. As in other gambling situations, even the experts don’t agree on the exact odds, but the Lancet – and it says this is a good bet – puts your chance of avoiding a “serious vascular event”, such as a heart attack or a operation, at 167 to one (if you are healthy with a low risk). And you have to keep taking them for five years.
Other studies have come up with figures that are even worse. The Cochrane Collaboration report found that healthy, low-risk people who take statins have a 1,000 to one chance of avoiding dying from a heart attack.
Another study found that if 10,000 people, who were healthy but at high risk, took statins for four years, there was no evidence they would live any longer. The study did find seven fewer deaths in the statin group but said that the number was so small it wasn’t statistically significant.
2. The side effects
Because the chances of benefitting personally are so small, it becomes very important to know your chance of side effects. Here there is even less agreement among the experts. The Lancet paper is remarkably gung-ho about statins, saying there was no need to worry about “possible serious adverse effects”.
Others are far less relaxed about the risks. Muscle damage has always been a concern but, while the evidence from trials puts it at about one per cent, others (especially clinicians who see patients on a daily basis) put if far higher, maybe up to 20 per cent.
This isn’t just unpleasant; it can seriously interfere with your ability to exercise, which is one of the best ways of avoiding heart disease. There is also a big debate going on about statins raising the risk of diabetes. They could give you a 200 to one risk of developing it; pretty close to the benefits.
3. The missing enzyme
Then there is curious case of the vanishing enzyme, CoQ10. The big statin trials never mention that statins, as well as cutting cholesterol, also block production of CoQ10, which is vital for the effective working of muscles – the heart is a muscle – and for producing energy. In Canada, statin packets come with a warning about this and advice to take a CoQ10 supplement. Here they don’t, and GPs rarely advise it.
4. Learn to love your cholesterol
Cholesterol has a number of important functions in your body, so it seems wise not to lower it without good reason. A one in 167 possibility of benefit doesn’t seem that good. Cholesterol is part of the membrane surrounding each brain cell (20 per cent of our total cholesterol is in the brain), where it controls, among other things, the transmission of messages through the nerve cells. One of the commonly reported statin side effects is memory loss and brain fog. Cholesterol is also the feedstock that the body uses to make all our sex hormones
5. It’s the lifestyle, stupid
Even the most ardent statin supporters pay lip service to the benefits of changing your lifestyle: eating healthy foods, exercising and so on. But doctors are not particularly good at helping you to do that. Making those sorts of changes is hard and you need support. So drugs are the easy option.
But a trial involving 20,000 people found that making just four of the most basic lifestyle changes put an astonishing 14 years on to their life span. These were: stopping smoking, cutting alcohol to moderate levels, exercising, and eating five portions a day of fruit and vegetables. Compared with going for a 167 to one chance of avoiding a heart attack, the choice is a no-brainer.
This piece is also on Jerome’s website, Body of Evidence, where he goes into more detail on the subject