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Friday, November 15, 2013

Statins – To Take or Not to Take?

And the controversy rages on. If you followed the article Experts Reshape Treatment Guide for Cholesterol and the editorial Don’t Give More Patients Statins in the New York Times in the last two days, you’d see the breadth of the issue.

The problem is that, while heart disease is the number one cause of death in the US, most heart disease is not necessarily caused by an elevated cholesterol or abnormal cholesterol pattern. The number one cause of premature heart attacks (and overall mortality) is smoking!

It is quite clear that people who have already had a heart attack are at a high risk for a subsequent heart attack, and those with type 2 diabetes carry a similar risk. These people should be treated with statins, if possible. Most experts agree.

What is one to do with the healthy person who has a high LDL (“bad cholesterol”), a family history of heart attacks, and faulty lifestyles such as eating the wrong foods and not exercising? Some people simply get away with it – without statins. According to the new guidelines, these people should still get statins, even if in retrospect they should not have had them. So how do you know who will “get away with it?” You don’t know for sure, but you try to better assess their risks.

Besides the usual physical examination and lab results, additional testing may be in order. This may include more sophisticated blood tests, such as those done by Berkeley Heart Lab or Boston Heart Diagnostics, and a variety cardiac stress testing (simple, radionuclear, or ECHO).

When there’s still a question, a non-invasive CT scan of the coronary arteries can be performed. This test determines the amount of calcium in the major coronary arteries. The higher the “calcium Score” the greater the risk of a future heart attack.

In my practice, I’ve had a fairly large number of patients with very high total cholesterol  and “bad cholesterol” levels who lived, or still living, with no statins and no heart attacks to a ripe old age.

So, my take is that statins are not for everyone, and a reasonable attempt should be made to identify those who are at an increased risk for a heart attack. And then treat.

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