It depends if a patient has multiple risk factors like a strong premature family history or if a patient has FH (familial hypercholesterolemia) or if a patient smokes all of these patients can be "healthy" but are at a greater risk.

I completely agree. the point is how to detect who are al high risks to developing CAD,so I would treat "healthy patient" but with heavy risk factors and in this context I would use imaging Ca-score in order to reinforce for example putting patients on statins 

The purpose of the debate is a good one: opposing points of view, new information

The first posting was incomplete and forwarded in error. That portion is correct but  what also needs to be stated as the Blog states, among many good points, that its intent is provide balanced views. The actual debate did provide that.  What I must object to is the video presentation by Dr. Seth Bilazarian.  It has no balance but is a diatribe only against the positions of Dr.Redberg and are totally over the top.  One example is suggesting anyone can buy statins for $50.00 a year-please give me that pharmacy's address.  Statins run more than that for one month.  Furthermore, there is no equal comparison -nor is one necessary-between statins and a healthy diet.  Dr. Redberg believes that statins have not yet been proved to be totally safe. That is a correct statement, even though many disagree. But you attack her ethics-that isunacceptable. You want to promote points of view through debate, allow your audience to decide who has the better argument-you needn't attack one of the physicians because you do not agree with their position. If you wish to correct a statement made by a debate participant-please stick to the issues and not the personal attack.  It is unprofessional and frankly casts doubt on your own interest in balanced reporting. Sorry, Dr Bilazarian, your intent is good but your commentary is way off base.

Dr. Redberg's approach is a regreshing entry in a fairly difficult decision making process.  I am asking each of the readers whether or not they take statins.  Do they exercise.  What is their diet like?  What is their stress levels like?

I can probably answer these questions for most.  I have had an event after bypass.  I am a very busy nurse practitioner in NE MIchigan.  After my bypass I made a committment to exercise.  My diet didn't change much, my thought processes have changed about priorities.  Statins have played havoc in my life.  I exericse agressively 6 days a week.  My blood sugar is climbing.  I take a statin twice a week because any more than that causes side effects that render me unable to work and participate in life.

As a clinician, I don't know how to advise myself.  Do I stop statins and risk another event.  Or do I take statins, develop diabetes and lose my feet.

I have chosen Dr. Redberg's path and have experienced documented decreases in lesion since in the LAD and carotids.  WE MUST get back to basics of good nutrition - preferably home grown, and basic exercise- not pills for every ills

It is up to the physician to advise, based upon the most up to date information he/she has.  If pharma hides the truth, how is it possible to be a "learned intermediary"?  That being said, anyone with a sufficient number of risk factors should be on a statin, but how high the dosage? I am very concerned that some docs will blindly accept JUPITER and act upon it in primary prevention.  That is the crux of the debate in the WSJ. I wonder why all the other statin mfg'rs didn't jump on that bandwagon?  I don't think Dr. B would favor putting Crestor in little packets at McDonalds to sprinkle on burgers. Oh, and as to the 50.00, that's if you get a 4.00 per month rx at Walmart.  It's not for any statin still on patent.

Thanks very much for your comments.  I certainly intended to speak against Dr Redberg’s position since I disagree with it and appreciate that you disagree with me and agree with Dr Redberg.  The blog is an opinion piece. As to the facts/data portion of your comment there are multiple sources for statins less than $50.00 per year.At Rite Aid simvastatin all doses can be obtained for $8.99/ month or $63.96/annually so prescription of simvastatin 80 mg half tab daily would cost $31.98 annually.You can find the available med list and description at http://www.riteaid.com/www.riteaid.com/w-content/images/pharmacy/Rx_Savings_Web_Directory_12_21_11.pdfWithout tablet splitting Walmart and Target offer Pravastatin and Lovastain for 3 months for $10 or $40 / year I hope this helpsThanks for posting

I really love the debate formats too, especially in the cardiology meetings. I cannot believe in the same breath you are saying that we all know the benefits of exercise and diet yet you require a randomized control trials. Let's think about  this for a second. We are talking about apparently healthy individuals who may be at risk and asking them to take a statin.
Using carotid IMT to track disease process has been successful yet who in their right mind is going to fund a study with diet and exercise vs a billiion dollar drug industry.

We know the benefits of lifestyle modification and we know the effects that take place on a biological level towards atherosclerosis yet getting out the precription pad seems to be many doctors course of action. Take some time with patients, learn about them and you will see them adopt healthy changes when you have the "serious" discussion that they may be heading for a heart attack or stroke.

Doctors have a power to maek a difference in their patients lives. Taking out a precription pad for apparently healthy individuals with no diagnosed heart disease is not always the answer.
Cardiac rehabilitation programs and heart attack and stroke prevention clinics are the answer, not always drugs. Give the patients a choice, because no drug is free of side effects. 

 

 

If you do not believe in cardiac imaging and calcium scanning (Redberg), then you would never use statins for asymptomatic patients to stabilize plaque. Blumenthal regularly scans asymptomatics for proper risk stratification. 

A targeted approach is, in my opinion, the only way to approach this topic.  On my free (and open to all) website at www.bowlinggreenstudy.org is presented a list of my publications and presentations on over 40 years worth of reading and practicing interventional lipidology and preventive cardiology.  In the publication in Experimental and Clinical Cardiology in 2005 I presented a table listing the incidence of atherothrombotic disease (ATD) per age group and Cholesterol Retention Fraction (CRF, or [LDL-HDL]/LDL).  It is my practice to treat patients with elevated CRF values about 10 years before their risk of ATD rises abruptly.  Using this regimen, only two of my treated patiients have suffered fatal AMI's so far this century, and one of them was a cigarette smoker who could not kick the habit, while the other was an insulin-dependent diabetic x40 years who suffered his first AMI at age 49 years and his second (fatal) AMI at age 72 years--not bad for the leading killer of Americans.  This table can also be found on-line in Advanced Studies in Medicine (Johns Hopkins) in the Febuary 2004 issue.

My feelings go in the same direction as agile.

This is the typical debate when it comes to discussing cholesterol and cholesterol-lowering medications, in this case statins.

On one side, the proponents of treating a maximal amount of people with statins. Mind you, many of these people these days seem to evolve, proposing that we should treat according to risk. My objection to this is that if you look sufficiently hard, you will always find a risk factor, and thereafter the patient is at risk. Jupiter is the perfect example: all studies done correctly show that CRP has very little predictive value but still it is now considered that you can treat normal LDL-level patients with statins for as long as you find some kind of surrogate risk factor, in this case CRP.

On the other side, those of us who are preoccupied by treating the individual in front of us. If an individual comes to me feeling healthy and that my assessment establishes that he/she does not have cardiovascular disease but may be at risk for it, because of his lifestyle, the simple fact of prescribing a drug places this individual among a patient population. I.e. I have made him sick while he came to see me healthy. This is a highly questionable attitude.

It therefore becomes of paramount importance that we must be sure that the individual in front of me will benefit by taking a drug that is not treating anything but a so-called risk. This benefit is far from having been established with statins in primary prevention.

What I notice in Dr Bilazarian's presentation of the debate is the typical pro-statin attitude. F.ex. Dr Redberg's "Less is more" feature is presented as an expression of therapeutic nihilism. Following what I said above, it is on the contrary one of the ways of being a better doctor. When she said healthy patient I do not think that she had in mind the patient with metabolic syndrome as you suggest but rather the patient who is feeling fine and maybe has one or two risk factors.

Another point which always gets on my nerves: asking for randomized controlled studies establishing that lifestyle is superior to medications. Could someone please tell me how I can make an individual exercise without knowing it and without the doctor knowing it. Asking for this simply means that you haven't given it a serious thought. The same is obviously true for diet.

Finally, the argument that you cannot get vegetables for 50$ a year is again curious. You forget that people do pay for eating bad diets also. So vegetables should be in place of the expenses caused by junk-food diet, which is probably a few hundred dollars per month.
I am not naïve: presently fresh vegetables/fruits have become more expensive. So the problem is still financial, but not in the sense that was put forward here.

If a significant proportion of the population can be induced to improve its' lifestyle, savings will be quite impressive. But as long as we continue to state that it is easier and cheaper to take a more or less inactive pill than to try to implement a highly effective lifestyle change, things will go on unchanged. And, of course, many people earn tremendous amounts of money in this way.

I wonder how often the statin-proponents really put things in balance with their patients, giving them an informed choice, i.e. "If you do change your lifestyle you will avoid taking a pill for the rest of your life, i.e. 30+ years". In my experience, a significant number of patients do seize the opportunity successfully. But it means that the doctor must be convinced himself. How many statin-followers have changed their lifestyle to the better, meaning they are convinced? Those who haven't convinced themselves can hardly expect convincing somebody else… And they are probably the majority.

Among other things, this is confirmed by the very moderate referral to rehabilitation after a cardiovascular event.

Finally I reassure you: I do not take statins and will never do so. And for the anecdote: my father had a cholesterol level of 9.4 mmol/l, with an LDL above 6, refused to ever take a statin, and died at the age of 94 without having ever experienced a cardiovascular problem. But mind you: he followed by taste a very Mediterranean diet, stopped smoking at the age of 30 and walked an hour a day. But of course, statin-proponents will just state that he was very lucky…

My husband Ed passed away from overdose of statin use 40 mg/ for seven years.

He was a brilliant businessman and a motivational speaker, that lost his ablitly to speak.

It was the most horrible and cruel way to die anybody can imagine! 

Officially the death was supposed to be due to Parkinsonian Lewy Body Dementia.

All the while,  while he was ill, time after time,  the doctors said he was definitely not suffering from Alzheimers. Yet, the autotopsy report it said he was having some signs of Alzheimers. I know better.  He had horrrible pains in his lems and electric shock feeling that traveled all over his body. He could not lift his arms above the elbow level for atleast year and a half before his death. What he really died of medicine induced Multible Dementia w. Lou Gehrigs Disease. I knew his symptoms better then any doctors. One neurologist said his condition mirrors one,  due to demyelination of the brain due Lipitor use. My husbands dementia was not dull, he suffered from lack of words while speaking. He also suffered from Trancient Global Amnesia. TGA. Sometimes he was able to talk clearly, and even give advice to me! Go and read "First Comprehensive Statin Study" byDr.Beatrice Golomb and get smarter! Also read a book written by a MD, Called."Lipitor, Thief of Memory. Or any writings by Dr. Peter Langsjoen. there ae multiple Medical Doctors across the World, that refuse to prescribe statins for the horrrible and disableling side-effects.  Any medication we take directly affets the brain, therefore any MD should have a degree in neurology as well. It should be a requirement, othervice, you are being medicated by clueless and ignorant doctors, that rely more ont the md reps words, then actual medical facts! By studying the facts for over 3 years, I can say with confidence that I know more of neurology and tha function of the brain,  then most medical doctors in America.

The High Spinning Pfizer executives and their corrupted doctors should be jailed for fraud, for mauling people to death! Justice must be served! And I approve this message, Marjatta Lavin