The Wide Gap Between What Should Happen and What Actually Happens

Two days, a prominent radiologist, about 4 years my senior, died of a sudden “heart attack”. Perhaps, if he had been on statins, this may have been averted.

In an ideal world, everyone who has a defined ASCVD risk (which we can also calculate on our own), would be on statins. And yet, less than half of those who would benefit, actually land up taking statins. There are many reasons; access to healthcare and affordability are major issues in low middle income countries like India [1], but the other important one is that of “misinformation” [2], especially among those individuals and social groups that can easily afford to take statins and have access to good healthcare.

I guess, I just can’t let go of this issue.

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In the first piece on the “matka of statin intolerance”, I started with the story of a healthcare professional (not a doctor) who thought that statins are no longer relevant because LDL levels are no longer important, something that he had read in the “Encyclopedia of WhatsApp”.

I remember that up to just around 7-8 years ago, I was also an “anti-statinist”. A couple of decades ago, a cardiologist friend of mine had told me that if statins can reduce fat in the blood, they can leech the fat from the brain - this is not true, but it made a little wary of statins. It is only when I started doing my own research that I realized how wrong I had been, but it still took me another 4-5 years of false starts, before I embraced rosuvastatin and got my LDL to below 70 mg/dl. And I am a doctor!

I have a close friend whose LDL hovers around 140 mg/dl, has a family history of coronary artery disease, a 10-years ASCVD risk of 11% and is a type A personality. He refuses to start statins…he wants to sort this out without “chemicals” as he says and there are so many like him, who resist anything that perhaps may need to be taken for life. It is frustrating trying to convince people like him that he needs to be on statins, sooner rather than later.

While I was writing the second nocebo effect article, I came across an article by Adam Nelson and his colleagues [3] that has tracked the extent of “statin misinformation” and the reasons why people don’t take a drug that actually saves lives.

This diagram says it all. With Dr. Steven Nissen’s permission, I have reproduced the diagram and the caption, as it is, without change.

Fig. 2 Flow diagram representing the vicious cycle of statin misinformation. Risks of statins are overemphasized and amplified by the media such that patients already have a preconceived notion or fear of statins when statins are proposed by an otherwise passive clinician. Patients take the prescription and seek out further information on websites, which are more likely to promulgate a narrative of fear and risk rather than benefit, thereby perpetuating a negative expectation of statin therapy. Patients develop symptoms that are misattributed to the “new” statin, which lead to a false belief of causation and ultimately non-adherence and discontinuation. Patients report the side effects that are falsely misrepresented in non-blinded observational analyses and subsequent media, which positively reinforces a message of harm and restarts the misinformation cycle

What is our “matka” here? If we are at risk for ASCVD and we would benefit by taking statins, but we don’t, because of our inability to sift fact from fiction, we will eventually be the loser. Statins save lives…period!

Footnotes:

1. Khatib R, McKee M, Shannon H, Chow C, Rangarajan S, Teo K, et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. The Lancet. 2016 Jan;387(10013):61–9.

2. https://www.escardio.org/Education/Practice-Tools/Talking-to-patients/arming-your-patients-with-the-facts-on-statins

3. Nelson AJ, Puri R, Nissen SE. Statins in a Distorted Mirror of Media. Curr Atheroscler Rep. 2020 Aug;22(8):37.