My take on the competing opinions on the use of cholesterol meds in “healthy” people which was recently published in the Wall Street Journal: 

These authors both have good “street cred” in the medical community,  and they nicely represent the two camps in this debate.  They write well – and both are a little sneaky.  They choose their words carefully, both in how they reference the literature that they feel supports their position, as well as that which they question. 

But lets start with the WSJ articles title.  It uses the phrase “healthy people”.  Is someone with very high cholesterol and significant atherosclerosis (vascular disease and hardening) who has just not happened to YET have their heart attack, healthy?  I’d say not.  And this gets at the heart of the debate. 

We do know that these drugs work – they lower cholesterol and they reduce heart attack risk.  We also know that many people take them without benefit, and at considerable cost and some risk.  We need a better way to identify those most likely to benefit.  There are some tools out there to help with this – such as CT scan angiograms (coronary CTA) of the heart arteries.  I'm not referring to the hyper-promoted screening coronary CT calcium score test – that test often disappoints.  I'm talking about an expensive (probably $2000 plus) test that carries some risks, but which gives a much better look at your heart arteries than the calcium score CT.  I need to be clear:  I'm not advocating  widespread use of  coronary CTA for screening.  I'm not aware of any published studies that have looked at it in risk stratification – that is, trying to find out who might benefit most from more aggressive preventive strategies.

 From a cost standpoint, this idea is intriguing.  Today, at drugstore.com, generic lovastatin at a typical dose costs 66 cents a day.  Newer, more-prescribed atorvastatin (Lipitor) non-generic pricing is closer to $2.50 per day IF you buy big pills and split them.  Generic Lipitor is now available at around a buck a day, sometimes less.  Anyhow – the cost (if you paid it all out of pocket) to treat your high cholesterol for 25 years ranges from $6,000 to $23,000. 

What would I do?  If I had close relations (father, lets say) with the early onset of heart disease and I had high cholesterol, I”d seriously consider taking statin meds IF weight loss, regular exercise and an excellent diet did not help after a 6 to 12 month trial of them.  I'd not stop the lifestyle changes when I start the med.   If I needed convincing, I'd think about forking out money for the CTA.  Maybe I get lucky and am one of those folks who does not have significant heart disease. Does this mean that I will get away with NOT taking statins?  No.  Could a good CTA report mean that I'm less likely to benefit from them?  Maybe.  Keep in mind that these tests provide only a snapshot, and that the disease is accumulative and often starts early.   If my heart arteries look excellent at age 20, I'm not home free.  If they look great at 50, that's better news.  Either way, I need to be paying attention. 

And what about all those folks who don't have a negative family history, or just don't know their family risks?  If they have high cholesterol, they too might benefit from statins.  These people might be aided by a test that gives them a better sense of their vascular status.

So, at this point in time, even with all the billions spent on heart disease research and prevention, we don't have all the answers.  At some level, it becomes a philosophical decision – you have to examine your tolerance for risk (test risk and prevention risk) and uncertainty.      

Stan Seagraves M.D., an internist who has practiced in Missoula for over 20 years. He is currently practicing hospital medicine at St. Patrick Hospital, and is medical director of their hospitalist program.

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