Giving patients statins for primary prevention may mean patients live longer – but only for a matter of weeks, according to a new analysis described in a hotly debated session at Pulse Live.
Macclesfield GP Dr Malcolm Kendrick said data shows that after five years of secondary prevention treatment with a statin, the average person just lives fourteen days longer as a result.
But Whitby GP and Cardiology GPSI Dr Terry McCormack countered that the latest, most robust evidence shows the benefits of statin treatment in primary prevention outweigh the risks even among people with the lowest baseline risk.
The debate ended in a draw between the loyalists and the sceptics, with Dr Kendricks appearing to win a few GPs to his side.
Speaking first in the debate, Dr Kendrick – a long-standing critic of established cholesterol-lowering practice and author of The Great Cholesterol Con – described the provocative findings from his as-yet unpublished analysis of the secondary prevention trial the Heart Protection Study (HPS).
He told delegates that looking at the data differently, focusing on life expectancy instead of mortality reductions, reveals that even the 1.8% of patients who derive benefit from statin treatment live only four months longer as a result of taking statins, while the remaining 98.2% do not gain anything. The average increase in life expectancy is 14 days.
He also argued that investigators and commentators have vastly overplayed results from primary prevention trials such as JUPITER, putting a spin on what are minimal absolute risk reductions in mortality while downplaying equivocal findings for other outcomes and the adverse events associated with statins.
‘We know that adverse event reporting is very, very low. Impotence, cognitive deficits, anger and irritation are all statin side effects that go unnoticed,’ Dr Kendrick said. The side effects are inevitable as a result of co-enzyme Q10 reductions, he added.
‘What I say to people is, statins may add fifteen years to your life – they won’t make you live fifteen years longer, but they make you feel fifteen years older,’ he concluded.
However, Dr McCormack said it was inappropriate to look at pharmacological treatments in terms of primary prevention in this way.
He likened the need for statins to having crash barriers on motorways – while the majority will not be crashed into, having them the full length of the road is the only way to prevent catastrophic events when needed.
‘It is worth remembering that 25% of people die from their first myocardial infarction – and we just don’t know who those people are going to be,’ Dr McCormack said.
Contrary to Dr Kendricks’ review of the evidence, Dr McCormack said there is overwhelming evidence that statins are beneficial – citing a 2012 Lancet meta-analysis by the Cholesterol Treatment Trialist Collaborators, which showed that among individuals whose baseline five-year risk of vascular events is below 10%, each 1 mmol/L reduction in LDL cholesterol results in an absolute reduction of 11 major vascular events per 1,000 people over five years.
Furthermore, there is evidence that some patients derive more benefit from primary prevention than do those receiving statins for secondary prevention, Dr McCormack said, while the extra costs associated with acute care for patients with major cardiovascular events accounts for the majority of healthcare spending on cardiovascular disease in the UK.
Reminding conference that pharmacological approaches form a small, but important, part of a multifaceted approach to primary prevention, Dr McCormack said that epidemiological evidence shows countries such as the UK that have adopted widespread statin use as part of their public health primary prevention policy are pulling ahead of others in terms of reducing cardiovascular mortality.
Asked by a delegate to give his views as NICE guidelines chief, Chair Professor David Haslam joked that he could not be seen to influence the debate – and declared the subsequent vote a dead heat.