"Should my dad be taking Lipitor?"
I recently received a text from my friend asking, “Should my dad be on Lipitor? His cardiologist hold him that all of his numbers looked good. And at the end of the visit, they told him that he should start taking Lipitor. Seemed kind of like as an afterthought as he was walking out the door.”
It’s an incredibly common situation: a doctor recommends a statin and a patient wonders whether any thought when into the decision at all. After all, doctors often say, “everything looks good” when things are suboptimal as long as there isn’t anything that puts you in imminent danger. Plus, it’s easier to just tell someone that they need to be on a medication than to counsel them about their individual risk factors and how best to modify them?
This decision is generally straightforward if you’ve had a heart attack - being on a statin is probably the right choice.
But for preventing a first heart attack? It’s a more difficult decision and one that’s fraught with a lot of misinformation as well as doctors who don’t interpret cholesterol panels with depth or nuance (or more importantly, don’t order the correct tests to begin with).
Wrong decision making goes in both directions here - there are a lot of people who are taking statins who do not need to be on them and a lot of people who should be on them that aren’t taking them.
How do we think about risk?
There are a number of standard heart disease risk factors that every doctor looks at - blood pressure, blood sugar, cholesterol, family history, smoking, obesity. Some of these are modifiable through lifestyle choices and some are not.
There are also a number of non-standard risk factors that we evaluate - metabolic syndrome, chronic kidney disease, autoimmune disease or chronic infection (diseases with increased inflammation), lipoprotein (a), premature menopause, and preeclampsia.
Huge amounts can be written on all of these individually, but I think that most of the medical decision making (and personal decision making!) about what to do boils down to the decision my friend asked me about above - should you be on a statin?
Statins are the most prescribed drugs in the world and Lipitor (atorvastatin) alone has made Pfizer almost $100 *billion* in revenue over the past 20 years. Even now that Lipitor has been off-patent for 8 years, it still generates $2 billion a year in revenue.
The numbers are insane. I suspect the fact that there are so many people prescribed statins who haven’t manifested heart disease helps to explain the proliferation of skeptics about their widespread use.
The ways we measure risk are imperfect
We use a few different methods to attempt to quantify a patient’s individual cardiac risk. There are a number of calculators that can be used to calculate approximate 10 year cardiovascular risk - meaning estimate your chance of having a heart attack over the next 10 years.
There’s one from the American Heart Association and American College of Cardiology (AHA/ACC). There are other ones based on large cardiovascular clinical trials such as the Multi Ethnic Study of Atherosclerosis (MESA) or Framingham.
While these are great for predicting risk across a population, they miss a lot of important aspects of individual risk. None of them incorporate all of the factors that increase your own personal risk. We certainly have a good sense of accuracy on the very high end and the very low end, but it’s the folks in the middle where the risk stratification becomes less reliable.
And when you’re thinking about taking a medicine everyday indefinitely, you really want information to personalize your own risk.
So when I’m talking to my patients about this decision - the ones who haven’t had a heart attack but may have some risk factors - I generally recommend additional individualized stratification.
A coronary calcium score is a great tiebreaker for this decision
A coronary artery calcium (CAC) score is a low radiation CT scan that lets us look to see if there is any calcium built up in the arteries around the heart.
You may have heard the term “hardening of the arteries” before. That’s calcification.
Any calcium in the coronary arteries - that is, a calcium score of any number over 0 - implies heart disease is present. Of course, there is a gradation in risk based on the amount of calcium (hence, calcium score), where higher numbers = greater risk.
CAC is better at reclassifying someone’s risk as either low (maybe ok to hold off on meds) or high (maybe it’s time to start something) than any other test that we have. Since it provides quantitative information about your own cardiac anatomy, this test can help to frame your own personal risk-benefit analysis.
So back to my friend’s question, “should my dad be on a statin?”
The answer is: it depends on a lot of factors - your own values and risk tolerance as well as all of your biomarkers and family history - but getting a coronary artery calcium score is a helpful piece of figuring out your own personalized risk.
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