This was a comment to the online article, “Viewing Catalyst’s cholesterol programs through the sceptometer“, written by Dr Justin Coleman, published on The Conversation on 4 November 2013. This was an interesting perspective offered by a clinical general practitioner following the rather problematic Catalyst program on cholesterol and statins.
Great article Justin!
I agree with most of your points, but as per Prof Clifton’s comment, the accumulated evidence has moved on somewhat from the meta-analysis from 2010. Newer systematic reviews and meta-analyses on the question of the effectiveness of statins in primary prevention have generally found some mortality and cardiovascular benefit. For instance, in a short piece for Medical Observer published last Friday, I looked at a meta-analysis from 2011 specifically in patients at low absolute CVD risk: http://vitualis.com/?p=505 Effectively, the magnitude of the effect is about the same as that found in the Ray et al. (2010) meta-analysis, but with narrower confidence intervals that no longer includes no-effect. Prof Clifton already quotes the 2013 update of the Cochrane systematic review which demonstrates a similar result.
The best evidence would suggest that statins probably do lower all-cause mortality and cardiovascular outcomes at all levels of cardiovascular disease risk. However, not all reductions of risk are clinically meaningful.
The pragmatic implications for routine clinical practice in the primary care setting, in my humble opinion, has not changed much though. There is little benefit for individuals at low absolute risk and statins are of questionable utility. For the individual, it is likely that there are other health priorities that should take precedence. So yes, I agree that there is substantial overtreatment with statins.
However, there is also substantial undertreatment as well. Statins are unambiguously beneficial in people with established cardiovascular disease and we know that medication adherence rates are not high. We should all be rightly concerned that media reporting lacking in these nuances contribute to the harm from non-adherence.
At the public health level the evolving data is certainly interesting. More definitive economic studies will need to be done before broad primary prevention recommendations can be made.