Should Healthy People Take Cholesterol Drugs?

If the county’s top doctors say President Bush, an avid exerciser they describe as being in “excellent” health, needs a cholesterol-lowering statin drug (search), do you, too?

Although the team of specialists at the National Naval Center in Bethesda, Md., declared President George W. Bush “fit for duty” after his annual physical exam on Saturday, they still recommended that he take a daily aspirin and a statin to help prevent heart disease.

Statins are the most widely prescribed cholesterol-lowering drugs and include Crestor, Lescol, Lipitor, Mevacor, Zocor, and Pravachol. High cholesterol levels increase the risk of heart attack, death, and other heart disease-related problems.

But Bush’s doctors said he had a “low” to “very low” risk of heart disease, and his total cholesterol level was listed as 170 mg/dL, which is considered within the normal range.

So why would he need a statin? According to the most recent guidelines for cholesterol treatment, a healthy diet and exercise should be adequate for a healthy 58-year-old with no major risk factors for heart disease, such as high blood pressure or diabetes.

Experts tell WebMD that the President’s cholesterol treatment plan may seem a bit aggressive, but it may be part of a growing trend in statin use.

“I can’t fault Bush’s management,” says Paul D. Thompson, MD, director of preventive cardiology at Hartford Hospital in Hartford, Conn. “It looks like the trend is to treat people more aggressively.”

Antonio Gotto Jr., MD, dean of the Weill Medical College of Cornell University in New York City, calls Bush’s treatment plan optimal rather than aggressive.

“It’s estimated that there are 46 million people who could benefit from statin treatment in the United States, and there are only about 12 million taking them,” says Gotto. “The problem is not overuse, it’s underuse. So I applaud President Bush’s doctors for being astute enough to realize the potential benefits to him from taking statins as a preventive measure.”

Risks vs. Benefits of Statins

Several studies have indicated that increased use of statins could significantly reduce the risk of heart attack, death, and possibly stroke in those at high risk for the disease.

Less is known about how beneficial these cholesterol-lowering drugs are in people at low risk for heart disease, such as President Bush.

But a study conducted by Gotto showed that people with normal total cholesterol but low HDL “good” cholesterol levels (below 40) had a 37 percent reduction in heart attack risk over five years by taking a statin.

However, cholesterol specialist Frank Sacks, MD, professor of medicine and nutrition at the Harvard School of Public Health in Boston, says the chances for benefit for any particular person at low risk for heart disease are minimal.

“Let’s say a person’s 10-year risk of heart attack is 5 percent, the statins would reduce that risk to just under 4 percent. So a person would have a maybe one in 100 chance of having a benefit from taking that statin,” says Sacks. “A lot of people would say forget it. Some people would say, ‘Well what do I have to lose?’”

Sacks says the fact is that many doctors will take a statin themselves even if they are very healthy because they believe the drugs are safe and have a low risk of side effects.

“But the chances that any of them, including President Bush, would benefit are very low,” says Sacks. “That’s the whole issue. What are the chances that he’s going to get a heart attack that could be prevented by a statin? There’s a very low chance of him benefiting, and that’s why statins aren’t recommended for everybody.”

Sacks says the risks associated with statins, such as those that recently prompted the FDA to issue a new warning for Crestor (search), are usually associated only with high doses of the drugs, which would not be used in someone at low risk for heart disease.

Researchers say studies have estimated the risk of death due to muscle injury due to statin use at about 1.5 deaths per 10 million prescriptions.

When Diet and Exercise Aren’t Enough

For people with optimal cholesterol levels, defined as total cholesterol level under 200 mg/dL and “bad” LDL cholesterol under 100 mg/dL, a healthy diet and exercise are usually all that’s needed to keep your heart disease risk under control.

For people with cholesterol levels above that or with other risk factors for heart disease, Thompson says the bad news is that diet and exercise usually aren’t enough to lower cholesterol levels to the desired levels.

“If people have a bad diet going in, you can get lots of improvement. But if they have a pretty good diet going in, it’s hard to get changes,” says Thompson.

In a best case scenario, Thompson says healthy diet and exercise changes can lower cholesterol levels by 20-25 percent in someone with high cholesterol. But he says most of his patients are not willing to make that type of effort.

That’s when a discussion about statin use should take place, say the experts.

Gotto says anyone over age 50, has one or two other risk factors for heart disease, and whose LDL stays over 100 after diet and exercise should be considered a potential candidate for a statin. Other heart disease risk factors include high blood pressure, diabetes, and smoking.

But just because statins were recommended for President Bush, that doesn’t mean that they’re appropriate for everyone.

What is important, Thompson says, is to discuss your heart disease concerns with a doctor you trust in order to get the best possible treatment for you.

“The President of the United States is never going to be a good example because people get treated differently when they’re a doctor or an important figure. But that doesn’t necessarily mean that they get treated better,” says Thompson.

By Jennifer Warner, reviewed by Michael W. Smith, MD

SOURCES: Antonio Gotto, Jr., MD, dean, Weill Medical College of Cornell University, New York City. Frank Sacks, MD, professor of medicine and nutrition, Harvard School of Public Health, Boston. Paul D. Thompson, MD, director of preventive cardiology, Hartford Hospital, Hartford, Conn. News release, The White House. News release, National Naval Medical Center. Wire reports. WebMD Medical News: “Nearly All With Type 2 Diabetes Need Statins.” WebMD Medical News: “Government Group's Drug Ties Not Disclosed.”WebMD Medical News: “Experts Urge a New Low for Cholesterol.” WebMD Medical News: “Wider Guidelines Urged for Statins.”