A new report from preventive cardiologists at John Hopkins and elsewhere provides a set of useful tips for physicians to help determine when cholesterol-lowering statins should be used. The report has been published in the Journal of the American College of Cardiology.
“To statin or not to statin’ is one of the most important questions faced by patients and physicians alike,” says lead author Seth Martin, M.D., M.H.S., an assistant professor of cardiology at the John Hopkins University School of Medicine and the John Hopkins Ciccarone Center for the Prevention of Heart Disease. “Our report offers concrete tips for clinicians on how to conduct this vital discussion and to reduce patient uncertainty and frustration in making this complicated decision.”
While statins are quite effective in lowering the amount of circulating cholesterol in the blood and halting and slowing down the formation of fatty plaque, in some rare cases, they can also precipitate the onset of other serious conditions such as muscle damage and diabetes. While the risk of these infrequent side effects pales in comparison to the benefits of these drugs, this risk-benefit balance becomes trickier in patients who only have high cholesterol and no actual disease or other risk factors that make them high risk candidates for heart attack and stroke.
The American Heart Association and the American College of Cardiology guidelines state that in patients with high cholesterol but no overt heart disease, the decision to start preventive treatment should be based on the patient’s likelihood of suffering a heart attack or stroke over the next decade. They recommend that preventive therapy should be considered in those whose 10 year risk score for suffering a heart attack or stroke is 7.5 percent or higher. However, as study author Neil J. Stone points out, the decision to start statin therapy should be based on scientific evidence, clinical judgment and patient preference and should be made on an individual basis.
Some key tips offered in this report include:
- Don’t get fixated on
the risk score and don't use it as a shortcut to expedite the
decision of whether a statin should be used or not. The score should instead be
used as a conversation starter and additional testing should be used in patients
with borderline scores. The Johns
Hopkins team urges clinicians to ask patients to use the risk-score calculator
prior to their visit and come armed with questions.
- Shared decision-making does not mean split decision-making. Physicians should give patients information but the treatment decisions should remain with the professionals.
- Do not restrict the statin discussion within a 15 minute appointment but instead spend time with the patient and have a comprehensive conversation about statins, even if that means spreading out the conversation over several visits.
- Contextualise risk. Don’t
just throw numbers at the patient but give them a meaningful perspective of
what the risk scores and results mean for the patient.
- Discuss the five M’s of
statin use with the patient. These include the five side effects: memory, metabolism, muscle, medication interaction
and major organ effects.
- Statins and diabetes.
Statin use has been linked to a higher risk of developing diabetes. This should
be explained to the patient. Patients with pre-diabetes should only
be treated with statins if they have a markedly elevated risk of heart attack
- Statins and memory. Ensure
that the patients know there is very little risk that statin therapy will
impair memory function.
- Statins and muscles.
Assure patients that severe muscle damage from statin use is exceedingly rare
and that minor aches and pains are common yet often benign.
- Aim for the highest
tolerable dose. To obtain maximum benefit, aim for the highest dose tolerable
in those without predisposition for side effects. Use lower doses in people
predisposed to side effects or taking medications that could interact with
- Pay attention to news
media. Periodically scan major news headlines about statins and heart disease.
This can help give physicians insight about main concerns and fears.
Source: the Journal of the American College of Cardiology
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