How doctors and patients view statins for primary prevention?
Statins, a class of cholesterol-lowering drugs, are among the most commonly taken medications worldwide. An estimated 28% of adults over 40 in the US were taking statins in 2013, up from 17% in 2002. But despite the prevalence of this drug, there is still debate among clinicians on whether the benefits of statins for some patients exceed the harms. Further, there is little known about the perceptions of clinicians and patients, who prescribe and take statins for primary prevention, respectively.
Which patients benefit from statins?
Statins are prescribed to prevent future cardiovascular events, for patients of both moderate and high risk. However, not all patients benefit equally from taking statins. People at a higher risk of cardiovascular events–particularly those who have previously experienced a heart attack or stroke–benefit more from taking statins than lower-risk patients.
The 2012 Cholesterol Treatment Trialists (CTT) meta-analysis, which included 22 trials with more than 130,000 patients, examined the effects of statins on people of varying risk levels. Together, these trials show that patients with heart disease at high risk of cardiovascular events taking statins reduced their absolute risk of heart attack or stroke by 2.24% and reduced their absolute risk of cardiovascular death by 0.46%. This means that 1 in 45 people in this risk group avoid a cardiovascular event by taking statins and 1 in 217 avoid death from heart attack or stroke.
But for people without existing heart disease in the CCT meta-analysis, the benefit was much lower: there was an absolute reduction of 0.4% in major cardiovascular events, and no statistically significant mortality benefit from statins. This means that 1 in 250 people in this risk group avoid a cardiovascular event by taking statins, and none avoid death.
Statins are not without side effects: muscle pain is a common side effect, affecting one in 21 people taking statins, and other studies have found an increased risk of diabetes associated with taking statins. The pill burden and financial cost (for branded statin drugs in particular) can also be taxing.
How do clinicians and low-risk patients perceive taking statins?
In a recent study, health services researcher at the National University of Ireland Galway Dr. Paula Byrne and colleagues conducted interviews with general practitioners and people taking statins for primary prevention, to better understand how they perceive the purpose of taking statins, and the potential benefits and harms.
A key takeaway from the interviews was that both clinicians and patients view “high cholesterol” itself as a disease in need of fixing, rather than a risk factor for heart disease. Statins are seen as the solution to high cholesterol, not a preventive measure taken to reduce the risk of heart attack and stroke. Patients generally perceived taking statins as a normal aspect of healthy living, and did not question the decision to take them as they might other types of drugs.
“The idea that ‘statins are necessary to treat high cholesterol’ regardless of other risk factors is deeply embedded in both patients and doctors.”Dr. Paula Bryne
Yet there was ambivalence among the participants about taking statins. Some participants noted that they would rather not be taking them, but because their cholesterol was “too high” they had “no choice.” Clinicians too were not all sure about whether increasing the number of patients on statins was a good thing. Some clinicians trusted in the guidelines, while others “noted a creeping medicalization” of high cholesterol and said they would not necessarily take the drug themselves. Clinicians also struggled to balance their desire to empower patients to make their own decisions with the knowledge that they could be blamed for future heart attacks if they did not persuade patients to take statins.
Byrne et al. found that some patients overestimated the benefits of statins, and believed that once you started taking them, your risk of heart attack was eliminated, rather than just reduced. One woman said, “It is a bit scary when you think that maybe you could get heart disease, even if you were taking [statins]. That is a whole different ball game.” None of the patients in this study said that their doctor had used a risk calculator or decision aids to assess their overall risk of cardiovascular events before suggesting they take a statin, although most of the doctors in the study said that they used these tools.
The results of this study shed light onto some of the reasons why so many low-risk people take statins. The authors write:
Ambivalence and negotiation abounded throughout the reports of our interviewees indicating a complex ‘muddling through’ by doctors and members of the public in the face of uncertainty. Paradoxically, it is this very uncertainty that may give authority to doctors to propose statins in spite of their doubts, and drives patients to accept them as a way to try to live a healthy life. This may explain the high level of the use of statins in low-risk people.