The Doctor’s Surgery
Theodore Dalrymple
A close friend of mine, a distinguished professor of clinical pharmacology, takes his statins only to please his general practitioner, who (he says) would be very upset if he refused to do so.
But, apart from wanting to please your doctor, is there any reason to take them? My friend has changed his opinion on this difficult question several times in the last 20 years.
If you already have angina, or have had a heart attack, a stroke or a transient ischaemic attack (a short-lived, strokelike episode, often a precursor to a stroke), the answer is pretty clear and universally agreed: take them.
But what if you do not suffer from angina, or have not had any of the aforementioned events? Here the question grows difficult and perhaps even unanswerable in the present state of knowledge.
There are two types of prevention – primary and secondary. The first is intended to prevent people contracting a disease in the first place; the second is to prevent the progression or repetition of a disease once contracted. They are not the same. Statins are good for secondary prevention, but their role in primary prevention is unclear. Of course, there is a much larger market in primary than in secondary prevention.
The matter is immensely complicated. People who do not have angina or who have not had a heart attack or stroke are not all the same. Some are fat, some are thin, some have a family history of cardiovascular disease, some do not etc.
Such studies of the question as have been performed are few and not entirely satisfactory. The answer is still unclear: the best doctors lack all conviction; the worst are full of passionate intensity.
Statins are not free from side-effects which are rarely, but not never, serious. They have a number of minor inconveniences – more common after the age of 65. The risk of side-effects has to be set against the potential benefits, but there is no common unit of measurement to compare personal cost and benefit, and in any case, people vary in what they consider worth putting up with.
Beware also the difference between relative and absolute risk. A drug may reduce the risk of a disease considerably compared with the incidence in people who do not take it, and therefore sounds a good bet; but if the chances of getting the disease in the first place are slight, a reduction of the relative risk by taking a drug means very little.
Nowadays the official recommendations for taking statins are so stringent that 61 per cent of the population over the age of 50 are recommended to take them.
Thirty years ago, the official recommendations meant that eight per cent of the population were recommended to take them. The change in the recommendations means that an increasing proportion of the population now takes statins without any benefit to itself (though much to the shareholders of pharmaceutical companies).
According to statistics, I have roughly a 20 per cent chance of suffering a heart attack or stroke within the next 10 years – as I write this, sometime between April 2020 and April 2030. If I took statins, that risk might be reduced by a fifth; that is to say, to a 16 per cent chance. But this is not the same as a reduction in my chances of dying, since I might die of something else in the meantime.
Should I, then, take statins? Would I recommend someone else in my position to take statins? Try as I might, I cannot think of the correct answer, because there is no correct answer.
All I can say with complete assurance is that I do not take statins.