The Wall Street Journal published a little debate between two prominent physicians about whether statins are appropriately used to prevent heart disease in patients with no history of heart disease.
This is an important question for jails and prisons partly because of the costs of these medications. If inmates without heart disease are getting no benefit from these drugs, why should we prescribe them?
You’ve got hyperlipidemia!
My understanding of the hard data behind statins is this:
1. People who have known coronary heart disease (they have had an MI, say, or a stent) should normally be on a statin no matter what their cholesterol values are. Statins work in this population both for those with normal cholesterol levels and those with high cholesterol. There is speculation that statins work in this group not by lowering cholesterol, but by some other mechanism.
2. The big studies on statin use in people without coronary artery disease have shown no benefit for these populations: Women and patients over 70 years old.
3. If you look at overall death rates and rates of MI and stroke, statins probably do not benefit men who are at low risk for developing coronary artery disease, even if their cholesterol numbers are high. Risk factors include smoking, hypertension, diabetes and age.
4. Whether statins are beneficial for men who are at high risk for developing coronary artery disease is controversial.
Fortunately for me, this is not often an issue in jails. If a patient comes into jail on a statin, I will usually continue it. Inmates rarely stay long enough for me to begin discussions of cholesterol numbers. But this is a big deal in prisons. Should a 50 year old inmate at low risk of developing coronary artery disease be started on a statin just because his total cholesterol is, say, 220? I would say no–he needs to be counselled on healthy lifestyle practices. But I would like to hear your opinions!