The Doctor’s Surgery Tom Stuttaford
Any resistance to this drug is quite unfounded, says TOM STUTTAFORD
ONE DAY in the 1980s I was having lunch at arguably the best lung and heart hospital in the country when a famous cardiologist came in and sat beside me. His greeting was unusual but succeeded in not only altering my medical practice but possibly in preserving my life.
‘Do you have so much as a cousin who has had cardiovascular disease?’
I replied that my grandfather had had a long history of angina before dying from a coronary thrombosis and that my uncle had died from a ruptured aortic aneurysm. I admitted that I had had high blood pressure since my thirties but that now it was well controlled. Even before the cardiologist started on his meat and two veg he had given me his opinion.
‘You should start immediately on statins, a new drug. Statins reduce the incidence of cardiovascular disease. You’ll have to continue with them for the rest of your life but they will increase your chances of avoiding a stroke or coronary heart attack and reaching a reasonable old age.’
The cardiologist explained that he had been taking part in a trial of statins and now had the time to review both his own results and those from other units. He was convinced that statins had the ability not only to reduce the levels of low-density lipoprotein cholesterol, the dangerous type of cholesterol, in the blood, but that doing this would lower the risk of cardiovascular disease, both coronaries and strokes. I was impressed by the statistics he showed me and by his conviction.
At the same time that statins were demonstrating their power to reduce the risk of heart attacks and strokes, they were triggering some of the more savage debates in medical practice.
The intensity of the campaign to disparage the prescription of statins may have been fuelled by the Treasury’s desire to limit costly prescribing, but it is undoubtedly true that many patients don’t care for any regime that involves taking a drug daily for the rest of their lives. The thought of this will bring out Green nature-loving instincts in the most phlegmatic of people.
Drug patents have expired and the cost of statins has now been reduced. NICE now recommends that the threshold for starting cardiovascular disease-preventative treatment should be lowered. In the opinion of these often sceptical experts, statins should no longer be considered only for prescription to patients who have a twenty per cent risk of developing cardiovascular diseases over the next ten years. The standard advice now is that they should be given to those with a ten per cent risk, too. Prescribing statins to all those who fall into this risk category would prevent 28,000 heart attacks and 16,000 strokes every year.
Currently there are 180,000 deaths from cardiovascular disease in this country every year. Caring for those with cardiovascular disease costs British tax-payers £8 billion a year. Reducing the causes of this liability would not only be of obvious and intense relief to the patients and their families but could also be of some help to their tax-paying neighbours. NICE has gone beyond suggesting that GPS should increase the number of patients who are taking statins: they also recommend higher doses. They suggest that as a primary preventative measure, 20mg a day of atorvastatin should be prescribed but if the patient has any evidence of cardiovascular disease he or she should be given 80mg a day.
A reader recently wrote to me asking if my recent silence on statins was because I had lost some of my enthusiasm for them. This is not the case. I am aware of their side effects but I am also aware that the really sinister side effect, that of muscle damage and consequent renal damage, is extraordinarily rare. It would become even more rare if liver function blood tests were carried out more often when patients first start statin treatment. There is debate over whether statins cause minor aches and pains but controlled trials show that this is unlikely. If, however, any aches and pains do become worse, a very simple blood test to estimate the levels of certain enzymes is called for. Statins may cause some insomnia. This is eased if the dose is taken in the morning rather than in the evening, even though this may have a small effect on their effectiveness. Statins can also sometimes affect digestion, in which case constipation or diarrhoea can be reduced by taking the statin in the evening, with supper, rather than with luncheon.
Statins do cause a slight increase in the incidence of Type 2 diabetes but it should be remembered that they also reduce the incidence of the heart and arterial complications of diabetes. There are some drugs that should not be taken with some statins, among which is amiodarone, a drug that can be very useful for people with some types of cardiac arrhythmia. Some patients claim that statins cause intellectual confusion and memory loss but if these problems persist, they disappear as soon as the statin is discontinued. Conversely, there is evidence that the long-term use of statins reduces the incidence of Alzheimer’s.