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High cholesterol treatment: what is the benefit? Understanding Statins and NNT

Everyone knows that a high cholesterol level can be harmful to health. Most people understand that this is related to the risk of a heart attack, and many know that cholesterol buildup is also related to strokes.

Statins are a group of drugs that lower cholesterol levels by slowing the rate of cholesterol production within the body. However, it is unknown if this is the mechanism by which the risk of heart attacks and strokes is reduced. Statins may be doing something more beneficial. Drugs that lower cholesterol by other mechanisms appear to be less effective in preventing cardiovascular disease. Statins include Zocor, Lipitor, Crestor, Mevacor, Pravachol, and Lescol. Statins have been shown to reduce the risk of death from any cause, death from heart attack and stroke, as well as non-fatal cardiovascular events.

Patients may assume that these drugs greatly reduce risk, but the results are not as optimistic as might be expected.

For patients who already have diabetes or cardiovascular disease, taking a statin regularly over the course of five years will reduce the risk of death from any cause from 9.6% to 8.5%. To achieve this reduction, 86 patients will need to be treated to avoid one death (the number needed to treat, NNT). Statin use reduces the risk of death from heart attack or stroke from 4.4% to 3.4%. This requires treating 109 patients to avoid one death.

Statins work best in patients younger than 65 years old. In this age group, 68 patients need treatment to prevent a cardiovascular event. In patients older than 65 years, this requires treating 111 patients. For women, the numbers are especially disappointing: 326 women over 65 must be treated with a statin for five years to prevent a cardiovascular event (heart attack, stroke, other), according to a meta-analysis in the medical journal. Lancet, October 8, 2005.

If you’re like my patients, you probably thought that taking a statin would cut your risk by at least half. Not so.

This is why the US Preventive Services Task Force does not recommend for or against screening for high cholesterol in women who are not otherwise at risk for cardiovascular disease. Other risk factors include smoking, family history, diabetes, and obesity.

If you were 80, would you take a drug that has a 1 in 326 chance of helping you? I would not do it. What if you are 55 years old and the odds of him saving your life are 1 in 10? These are the kinds of questions to ask your doctor before starting treatment for high cholesterol. The goal is not just to reduce the number in a lab test. The goal is to reduce the risk of a life-threatening or debilitating disease.

Copyright 2010 Cynthia J. Koelker, MD

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