Sandra is a 53 years old high school teacher. She is married and has three children. She has enjoyed good health all her life. There is no history of any serious illness. She was admitted to hospital once, when she was 13 years old and had to have an appendectomy. She smoked cigarettes for a few years, but quit twenty years ago, before having her first child. She exercises regularly, walking and jogging are her favorite. She also does some light weight lifting in the gym, once or twice a week, during the wintertime. She is normal weight, body mass index (BMI) is 24.0.
Sandra’s father diet of a heart attack when he was 55 years old. She was fifteen when he died. Although her dad was a smoker for many years and overweight, Sandra has always been aware that she might end up having heart disease. That is one of the reasons she has been so determined to take good care of herself. Her blood pressure has always been fine but her cholesterol has been to high for some years. Her family doctor has discussed cholesterol lowering medication with her, but she was reluctant. Somehow she did not like the thought of a lifetime medication. Sandra has read a lot about diet and how to lower cholesterol. She follows the traditional advice. She avoids trans fatty acids and saturated fats, she seldom eats red meat, when she does she cuts out the fat. She eats a lot of whole corn bread, vegetables, fruit, chicken and fish. She loves chocolate, but tries to stay away from it as much as she can, which she often finds difficult. Her cholesterol levels have been rising slowly for the last few years, which worries her a lot.
Six months ago, Sandra’s ten year older brother, Jon, had a heart attack. She had warned him again and again about his lifestyle because he reminded her so much of their father. Jon is a smoker, overweight, does not mind what he eats, and is totally uninterested in exercise. However, he was lucky because the damage to his heart muscle was minor. He had an early angioplasty (PCI) where the blocked artery was opened up and the narrowing in his coronary artery covered with a stent. His prognosis is considered relatively good and he has been urged by his doctor to take his medication regularly. Jon is very serious about all this. He became quite scared when he had his heart attack. He has not smoked since then and he has been reorganizing his dietary habits. He is taking six different types of medication, two types of blood thinners, two different tablets to lower his blood pressure, one medication to treat a newly diagnosed type-2 diabetes and finally a statin drug to lower his cholesterol.
Suddenly Jon was very concerned, not only about his own health, but also the health of his sister. He called Sandra soon after his heart attack. “Sandra, I asked my heart doctor about you. He says that you absolutely must take a drug to lower your cholesterol. Otherwise, you will end up with a heart attack as I did, and I’m not sure you will be as lucky as I was. Sandra, please think about it. Do it for your kids”.
Sandra came to see me a month after Jon´s heart attack. She told me the story about her father, his heart attack, his sudden death and how it had affected her. She told me the story about her brother, his illness and how it had made him reconsider his lifestyle. Sandra had been healthy all her life. She had no symptoms or signs of heart disease. But she was terrified. She had a dreadful fear of having a heart attack and not being able to she her children grow up. She feared missing out on the joy of seeing her grandchildren. She did not like the thought of taking a drug to lower her cholesterol. She had a friend who had experienced terrible muscle pain on such medication. However, she was ready to do whatever it takes to avoid a heart attack, if not for herself, then for her children and grandchildren. If that meant taking a drug, she was ready to do it.
Sandra’s story made me think a bout how doctors inform and recommend their patients. How do doctors translate their knowledge into a meaningful recommendations. Sometimes these issues are very obvious. If there is a tumor that can be removed, you recommend surgery. Drug therapy for testicular cancer in men is not easy, but it in most cases it cures the disease. Medical treatment of glaucoma will prevent blindness. In these cases it is easy to recommend the patient; “this is the way to go, you must have this treatment” or “surgery is the only cure, so there is no doubt which way to go”. However, cholesterol lowering therapy in primary prevention is a totally different story.
Here is Sandra’s recent lipid profile:
- Total cholesterol 7.4 mmol/L (305 mg/dL)
- HDL-cholesterol 1.7 mmol/L (66 mg/dL)
- Triglycerides 1.1 mmol/L (97 mg/dL)
- Calculated LDL cholesterol 5.2 mmol/L (201 mg/dL)
If you are not acquainted with the numbers, I can tell you that both total cholesterol and LDL-cholesterol are elevated which is generally considered undesirable. According to the National Cholesterol Education Program (NCEP), her total cholesterol is defined as high and her LDL-cholesterol as very high. Her blood pressure measured 136/82 mmHg which is considered normal.
So, how could I help this healthy middle-aged woman with high cholesterol ? How important is lowering cholesterol in this situation? How could I help her reduce the risk of having a heart attack? How could I diminish her anxiety which was really affecting her quality of life. Should I prescribe lifelong therapy with a statin drug? I guess I had a few alternatives.
Firstly, I could continue with the type of “scare tactics” used by her brother. “Sandra, the high cholesterol is your only modifiable risk factor. Despite your healthy lifestyle, it is going up. If we don´t treat you with a cholesterol lowering drug you may end up having a heart attack. Coronary artery disease runs in families. You cannot help it. Your liver is simply producing too much cholesterol. It will end up blocking your arteries. If I prescribe a cholesterol lowering drug, your cholesterol level will drop 25 – 30 percent. Statin drugs are very helpful in this respect and side effects are very rare”.
Believe me, this would be an easy solution for me. It might take five minutes. I would take her back to my office in three to six months and measure her cholesterol. I guarantee that she will be happy with the results. You can count on that statins lower blood levels of total cholesterol and LDL-cholesterol. A thirty percent drop in cholesterol levels might even relieve her of some of the anxiety. Some doctors might use this approach because they really believe that statins work. They may even acknowledge that the benefit of statin therapy in primary prevention is small in low risk patients, and that data are less convincing for women than men. However, they might motivate statin therapy anyway by saying ” Let’s give her the benefit of the doubt”‘.
So, by prescribing a statin drug I would indeed lower her LDL-cholesterol. But would I improve her pognosis? That’s unlikely if we look at the clinical trials on the use of cholesterol lowering drugs in primary prevention. However, I could be providing her with false security which might maker her feel better.
Secondly, I could follow the theories of the so-called cholesterol skeptics. “Sandra, cholesterol is an important substance for the human body. Our liver produces cholesterol. It is an important part of cell membranes and your body needs it to build some important hormones. Cholesterol does not cause heart disease. Therefore, a cholesterol lowering drug will not help you”.
However, in my opinion, this would be a pretty one-sided information as well. Although the exact role of cholesterol in atherosclerosis and heart disease has not been clearly defined, without cholesterol and lipoproteins, cardiovascular disease as we know it would not exist. So, cholesterol plays a role in heart disease, along with many other additional factors. Statins influence the atherosclerotic process, although we don´t know for certain whether this is due to lowering of LDL-cholesterol, reduction of inflammation or some other mechanisms. Furthermore, we know that statins reduce mortality in patients with documented coronary heart disease.
Thirdly, I could use a more informative approach. “Sandra, your brother has a documented coronary disease. A number of studies have shown beneficial effects of statins in such circumstances. We know that statin therapy improves survival in patients with coronary artery disease. On the other hand, a recent study has indicated that the effect on mortality may be less pronounced among women than men. Clinical guidelines recommend statin therapy for men and women with a history of cardiovascular disease. This is based on scientific evidence.”
“Sandra, the situation is different in primary prevention. In your case, when there is no known cardiovascular disease, the positive effect of statin therapy is much smaller. Despite your cholesterol levels and your family history, you fall in to the category of a low risk patient, due to the absence of other risk factors. According to currently used algorithms your risk of having a heart attack in the next ten years is less than five percent. A recent Norwegian study has indeed brought into question the relationship between cholesterol and survival, particularly in women.”
“However, a there is data available indicating that statins may work, even for low risk patients, although the effect is small. In patients who have never had heart disease and are taking statins to lower their risk, the reduction of heart attacks and other major events is about 2 per 100, over a five year period. This means that, fifty patients have to be treated with statins for five years to prevent one event. Some people who take statins experience side effects. Muscle and joint pain is most common. Other uncommon side effects are muscle damage, liver damage, digestive problems, rash or flushing. Recently, however, other side effects have been highlighted. Thus, statin therapy has been associated with the risk of developing diabetes and neurological side effects such as memory loss and confusion.”
I chose the last approach, which was definitively not the easiest. Of course Sandra was confused after the long speech. But she is a clever lady. She asked: “Doctor, what would you do if you were me? Would you take a statin drug”? I said: “No, probably not. In your case, the risk of side effects is probably higher than the possible benefit”. According to recent European guidelines on the prevention of cardiovascular disease, lifestyle intervention should be recommended for you. However, according to these guidelines, drug treatment should be considered if blood lipids remain uncontrolled. So, I suggest we do not give you medical treatment. Keep up with your healthy lifestyle, exercise and healthy eating, and we will take a look at your cholesterol level again in six months.
Sandra called me a few months later. “Doctor, I wanted to tell you that Jon, my brother talked me into meeting his cardiologist. He definitively recommended drug therapy. I have been taking a statin drug now for five months. It really works. My total cholesterol has dropped to 4.5 mmol/L (174 mg/dL). I must tell you, I feel very relieved……..“. Then I realized how cholesterol lowering drugs can make people happy.