This transcript has been clearly edited.
Well, everyone. Be prepared. I’m going to fight about statins again. If you’re the type of person who likes to fight over whether Bettamax is better than VHS, you’ll love this! This is About the second thought.
We love to discuss cholesterol. It all lives for some people. In fact, part of the anti-cholesterol crowd has become anti-suckerers, so for penny, for a pound? But this is not new, and people have been promoting anti-cholesterol messages for years.
1989, Atlantic Ocean We’ve released the cover called Cholesterol myth. He said lowering cholesterol is not possible next to your diet, and is often dangerous with drugs, and that doesn’t help you live longer. And there’s no need to search online before some “healthbro” tell you to eat six raw eggs for breakfast, as cholesterol will make you stronger. Maybe you saw the movie Rocky Many times, I don’t know.
The problem with trying to speak reasonably about cholesterol is that this debate has been going on for decades. Has a much longer written work on the discussion of cholesterol Medscapeso you can check it out. But basically, cholesterol skeptics weren’t too wrong in the 1960s, 1970s, and 1980s.
Dietary and epidemiological studies were suggestive, but they were largely inconclusive. And if you were there, you probably would have said the same thing. Furthermore, drugs that had to be treated for cholesterol Cholestyraminenot actually used today. Frankly, they smoked.
that’s why, Atlantic Ocean The cover was really not wrong. Dieting is difficult, and most of them are unsustainable for a long period of time. Because people are human, not cybernetic androids (at least, not yet). And the medicine was terrible. However, the statin era began, 4S Trial It really showed impressive cardiovascular benefits. That should end the cholesterol discussion. Except that it’s not.
That’s because people don’t want to change their minds (see social media), and in part people were rooted in their positions in the ’70s and ’80s, and people couldn’t forget the vitreous that they had been lobbed against them. And some people just couldn’t keep up with the data.
Before reaching the main point, statins reduce major cardiovascular events. They reduce mortality. They are studied in women. They are being studied in older populations. (Be prepared for actual controversial points) The side effects of many statins, especially muscle pain, are the result of the nocebo effect.
Another thing that really bothers me is that the statins are already there, not the only medicine for cholesterol. In the 1990s there were no statins or anything, but that’s not true anymore. I’ll admit, ezetimibe Not the most powerful and doesn’t like needles, so someone is very much asking for regular injections of PCSK9 inhibitors. So, did we learn that during Covid that it is not?
I’m not a fantasy. If inexpensive oral medications are present, first-line therapy will not be initiated with more expensive injectable medications. But at least, can you agree that continuing to discuss statins is a bit ridiculous, if there should be issues with lowering cholesterol? Because that’s the point. Cardiovascular benefits depend entirely on how low cholesterol is. Whether you do it with fibrate or Niacinor statins, or PCSK9S – mechanism is not important. What makes the difference is the ultimate result of cholesterol. Certainly, you won’t get too banged for your money with fibrate or niacin (and I don’t use them for exactly that reason). The key is low cholesterol.
It really doesn’t matter how you do it.
So why are people still discussing statins? Thanks to the new one, it’s coming back Prevents risk calculators. If you’re in primary care, it’s probably a bit confusing that we keep switching from Framingham Risk Score In Pooled cohort equations New prevention risk calculator. Let’s put that aside for now.
Yes, people discuss whether they overestimate or underestimate the risks of some people, but it’s difficult to predict the future. So I have never won the lottery and have to continue making these videos to buy groceries. However, there are ways to identify low-, medium-, and high-risk individuals. I don’t think he really chose to fight me when it comes to dealing with high-risk groups. It is the low-risk group that everyone is bothered by and plagued by. So, do we deal with them?
These are two problems. First, does lower cholesterol in primary preventive patients improve outcomes? And two are there any cost-effectiveness? Because these are very different questions. First of all, is cholesterol important for primary prevention? Well, yes – yes. A meta-analysis of all statin trials conducted over the last 20-30 years gives a rather clear linear association. However, secondary prevention causes a larger slope. If you lower your cholesterol by 1 mmol/L (yes, you use an SI unit, but you get over that), the cardiovascular hypotension will have a greater effect on secondary prevention than primary prevention. This makes sense, as the most sick patients always benefit the most from treatment. Antibiotics are life-saving for someone Sepsis Also, if you have a urinary tract infection, it’s not that impressive. But they work with both patients.
So, does statin and cholesterol reduction work in primary prevention? Yeah! Here are a few different reports that you can draw: 2013 Cochrane Review and USPSTF Review for 2016and they both showed benefits. Nowadays, everyone likes to argue that these reports do not show mortality rates for the use of statins in primary prevention. But go back and read those papers – they both showed a reduction in all-cause deaths. It wasn’t a major reduction, but there were reductions.
Let’s take a look at the USPSTF review. The absolute risk reduction of all-cause mortality rates due to statins was 0.4%. It’s not zero. Whenever someone claims that statins do not reduce mortality, call them liars. A 0.4% reduction in absolute risk is the number required for 250 treatments (NNT). It’s obviously not impressive, but it’s not that bad either. Remember 250 NNTs in 1-6 years. Primary prevention is long-term. It’s not race, it’s a marathon. This is applied to the entire population over the years and the mortality benefits begin to be summed.
Also, it is difficult to prove the benefits of all-cause mortality, as people are now far less likely to die from a heart attack. Defibrillators, stents, and much more effective medications reduce mortality. Although mortality cannot be shown in a non-death population, it hinders cardiac-related clinical endpoints. Heart attacks, strokes, and even obtaining a stent are no longer considered extremely risky. Look at the clinical benefits of complex cardiovascular events. The absolute risk reduction is 1.39%. It’s 72 NNTs in 1-6 years. I think it’s pretty good, it takes everything into consideration.
Here we arrive at the second, more controversial question. Is it cost-effective? That kind of thing depends on you. Can we really value human life? So yes, insurance companies do that all the time. Obviously, we are not going to put everyone on statins. It’s not cost-effective. But where do you want to draw the lines? How low is the low risk? How high is the high risk? It is primarily a subjective question. Just as everyone argues about which risk prediction formulas to use and whether or not to draw a threshold. Basically, it’s a discussion of who has a better compass, not whether the earth is round or not.
Statins work even for primary prevention. Are numbers necessary to handle them properly? If you want to know what I’m thinking – yes. Although higher-risk patients benefit more than lower-risk patients (and ultimately we need to stop discussing how to define them), cardiac rates are declining as they are becoming more aggressive about smoking cessation policies, blood pressure targeting and diabetes treatment. We have less heart disease because we are more aggressive in controlling risk factors than before our generation.
There is now something called the population paradox. Small benefits for individuals can have a major impact when applied across the population. Is an NNT of 72 sufficient? Well, statins aren’t free, but they’re pretty cheap considering they’re all generic now. They have side effects (as with all medications), but many of these side effects are due to the nosebo effect. They do not cause cancer, dementia, or make the brain mushy.
Some people do honest cost-benefit analysis, while some are Doodle pseudo-science enthusiasts who think Kool-Aid is drunk and statins are killing everyone.
In any case, cholesterol is a Cardiovascular risk Factors and you cannot deny it exists. Is your patient at sufficient risk to justify treatment? I’ll leave it for you to decide. But statins work – don’t let anyone tell you. for MedscapeI’m Christopher Labos.
