Earlier this year, the editors of the Archives of Internal Medicine in the US launched a series entitled ‘Less is More’ – essentially to highlight the overuse of investigations or treatments in medicine. One example they cited was the use of statins for people without known heart disease, saying that this practice has “known adverse effects despite the absence of data for patient benefit…” [1].
The latest edition of the journal carries a response to this comment from several doctors who attempt to make the case that statins do indeed have a role in what is known as ‘primary prevention’ of cardiovascular disease (i.e. treatment in individuals with no known cardiovascular disease or previous heart attack or stroke) [2].
Among other things, the authors write about how studies show that in primary prevention, one meta-analysis (collection of several studies) showed statins reduced the risk of ‘major coronary events’ (e.g. fatal and non-fatal heart attacks) by 30 per cent. This sounds impressive, but in the primary prevention setting, overall risk of heart attacks is generally low, so a 30 per cent risk reduction translates into only a very small actual reduction in risk in the real world.
Also, this particular meta-analysis included data from studies which had included data from individuals with known cardiovascular disease. These individuals, actually candidates for ‘secondary prevention’, are at high risk of further problems. Their inclusion with primary prevention data queers the pitch and makes the benefits in primary prevention look better than they are in reality.
To properly judge the impact of statins in primary prevention, we need to look at data from primary prevention only. To date, only one meta-analysis has done this [3]. I have written about this study here. The most notable result from this meta-analysis is that statins (in primary prevention) do not save lives.
Despite the objections of some doctors, the editors of the Archives of Internal Medicine stand by their claims about statins. In a response [4], they draw our attention to the fact that the objections used inadequate data and fail to acknowledge the commonly reported adverse effects of statins including “memory loss, muscle pains, weakness and liver function abnormalities.”
They end with this damning statement: “For a medicine to be recommended to healthy patients for a lifetime of use, there should be robust evidence that this regime will reduce suffering or extend life, and evidence that the benefit outweighs adverse effects. Until there is such data for statins for primary prevention, we will continue to classify it as an intervention without known benefit, but with definite risks, in our Less Is More series.”
References:
1. Redberg R, et al. Diagnostic Tests: Another Frontier for Less Is More
Or Why Talking to Your Patient Is a Safe and Effective Method of Reassurance. Arch Intern Med. 2011;171(7):619
2. Minder CM, et al. Making the Case for Selective Use of Statins in the Primary Prevention Setting. Arch Intern Med. 2011;171(17):1593-1594.
3. Ray KK, et al. Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65 229 participants. Arch Intern Med. 2010;170(12):1024-1031
4. Redberg R, et al Editor’s Note—To Make the Case—Evidence Is Required. Arch Intern Med. 2011;171(17):1594.
