Debate: Should healthy men with elevated cholesterol levels take statins?

Doctors debate whether men with elevated cholesterol levels who are otherwise healthy should still take statins, in a new series in JAMA, Dueling Viewpoints.

The question posed to the physicians: “Should a 55-year-old man who is otherwise well, with systolic blood pressure of 110 mm Hg, total cholesterol of 250 mg/dL, and no family history of premature coronary heart disease (CHD) be treated with a statin?”

Michael Blaha, MD, Khurram Nasir, MD, and Roger Blumenthal, MD, of Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins, answered “yes.”

They acknowledged that the foundation of treatment for patients with elevated cholesterol levels is diet and exercise, but they argued that statins could be a critical adjunct for those identified to be at increased risk for CHD. There is no logic in waiting for a myocardial infarction before starting statin therapy, they stressed.

If clinicians are unsure of the risk of seemingly healthy patients with elevated cholesterol levels, the use of coronary artery calcium (CAC) screening can help.

“The CAC scan enables clinicians to direct statin treatment at the disease (coronary atherosclerosis) that they propose to treat and illustrates the concept of risk-based, individualized decision making,” they said. “Statin therapy would not be recommended if a CAC scan revealed a score of 0.”

Rita Redberg, MD, and Mitch Katz, MD, of the University of San Francisco, California, took the opposite position, arguing that healthy men should not take statins because there are other effective means to reduce cardiovascular risk, including weight loss, dietary changes, and increased exercise.

“These strategies are effective in increasing longevity and also result in other positive benefits, including improved mood and sexual function and fewer fractures,” they said. “Although these strategies are challenging, prescribing a statin may undermine them. For example, some patients derive a false sense of security that, because they are taking a statin, they can eat whatever they want and don’t have to exercise.”

Redberg and Katz noted a recent meta-analysis in healthy but high-risk individuals showing no reduction in mortality with statin therapy, as well as a recent showing similar results. Their viewpoint also highlighted the adverse effects associated with statins, including cognitive defects and diabetes.