Monday, 11 a.m. ET
Science: Preventing Heart Disease
Monday, November 10, 2008; 11:00 AM
Washington Post Staff Writer Rob Stein was online Monday, Nov. 10 at 11 a.m. ET to discuss a new study that could transform efforts to prevent heart attacks and strokes.
A transcript follows.
At a presentation to the American Heart Association, Paul M, Ridker of the Brigham and Women's Hospital in Boston," showed that a simple blood test could spot people who are at increased risk and that a widely used drug could offer potent protection against heart disease.
Read more in Stein's article: Study: Blood Test Can Spot Risks for Heart Attack, Stroke
Rob Stein: Hello everyone, and welcome to this discussion about this interesting new study about statin drugs and heart disease. The idea that statins, which are already widely used to prevent heart attacks, might be useful for those whose cholesterol is normal, is certainly raising a lot of questions. I see we've got a bunch already waiting. So let's get to it.
Eads, Tenn.: When I had a heart attack in 1983 at age 37, I was told that I did NOT have high cholesterol, but my HDL was a reading of 17, which is extremely low. My HDL remains below normal -- it was 32 at my recent lipid profile checkup. Anyway, I am an example of one whose "inflammation" could have been a tell-tale-sign. I have had 3 bypass surgeries in the past 25 years (1983, 1994, 2004), but my statin drugs have most likely kept me alive and have given me a quality of life that I otherwise would not have enjoyed.
Rob Stein: Thanks for sharing your story with us. Yes, cases like yours are a big motivation for studies like this one. About half of heart attacks and strokes occur in people whose cholesterol looks fine. So researchers have been trying figure out other ways to identify people at risk. This study provides strong support that measuring the amount of inflammation in their bodies might offer a way to find those who are still at risk even though they do not have high levels of the so-called "bad" cholesterol (los-density lipoprotein or LDL cholesterol).
Alexandria, Va.: Statins seem to be amazing drugs, but hormone therapy for women also was thought to be amazing before all the evidence came in. Are you reassured that these really are wonder drugs with relatively few side effects? (For example, I know some people who swear they developed memory problems after taking them and I don't know whether this has been looked into thoroughly.)
Rob Stein: You make a very good point. No drugs come completely risk-free, and there's always concern that unforeseen side effects will occur, especially when lots of people start taking them. I have not heard concern about memory problems from statins. Generally, they are considered very safe, though they can in rare cases cause muscle pain and tenderness (known as myopathy) and liver damage. And in this study the researchers did find some evidence that suggests there may be a slightly increased risk for diabetes. But the researchers suspect that might not be a real increased risk.
Washington, D.C.: The numeric difference between study participants who suffered heart attacks and those who did not is low. Why should we credit broad extrapolation from these results?
Rob Stein: Yes, the actual number of heart attacks, strokes and other "events" was relatively low. But the relative reduced risk found in the study was surprisingly high--actually about double that seen in earlier statin trials. And those trials have been considered strong enough to justify lots of people taking these drugs. That's because spread over lots of people these reductions in risk can prevent a lot of heart attacks and strokes.
Eads, Tenn.: Do you feel that this test should be a part of our regular doctor checkups?
Rob Stein: Well, that's something that an expert panel panels are planning to examine. In fact, the head of the National Heart, Lung and Blood Institute said a federal advisory panel is planning to do exactly that. Some doctors already do routinely test middle-aged and elderly patients for the CRP levels, and use that information in deciding whether to recommend their patients take statins.
Silver Spring, Md.: My concern with this new treatment standard is two fold: Once again it touts a pill as the answer instead of exercise and diet, adding to our "magic bullet" mentality to health. Also, it would seem very, very costly to put so many people on Crestor, or any other statin that people would now have to take their entire lives.
Rob Stein: Several experts I interviewed for this story expressed exactly those concerns. Everyone agrees that the first thing anyone should do is try "lifestyle interventions," such as exercising more and eating better. But for some people that is not enough. The cost issue is a big one. And experts are estimating that this could cost billions of dollars, especially if doctors prescribe the statin used in the study, which is not available in generic form. But other statins that are available in generic form also lowers CRP levels, and are much less expensive. And the authors of the study argue that the money that would be saved by preventing heart attacks and strokes would offset the costs of doing the tests and prescribing the drugs.
Washington, D.C.: My husband has waist greater than 40", but he exercises alot (over 1 hr per day) -- how do we know if a statin is appropriate. His cholesterol reading was 205.
Rob Stein: Well, anything above 200 is considered "borderline high."
Anonymous: Can the statin drugs reverse plaque build up? How does it work?
Rob Stein: Yes, there has been some previous research that has indicated that intensive statin therapy can actually reverse plaque build-up.
Arlington, Va.: Who funded the study?
Rob Stein: The study was funded by AstraZeneca, which makes Crestor, the statin used in the study. The researchers, however, say the company had no influence over how the study was conducted or how the data was analyzed, and that a completely independent data monitoring committee oversaw the study and made the decision to stop it early because the results were so clear.
Shepherdstown, W.Va.: Is the correlation between the inflammation indicator and heart attacks better than that between cholesterol and heart attacks or does this only work well when you screen out the high cholesterol's first?
Rob Stein: I'm glad you asked that question because it's important to stress that cholesterol clearly remains an important risk factor for heart attacks and strokes. What this study suggests is that hsCRP offer another way to assess someone's risk. It could help doctors and patients decide whether someone should go on a statin if their cholesterol level is borderline high, for example. If their hsCRP is clearly high, that could tip the balance. The debate is about what someone should do if their cholesterol is normal but their hsCRP is high. This study suggests they may still consider going on a statin, especially if they have other risk factors (such as a family history or are overweight). But not everyone agrees.
Virginia Beach, Va.: I have had the CRP test and my doctor said the results were in the intermediate range, but he was at a loss on how to change that. Are the statin drugs the only way?
Rob Stein: Eating better and exercising more might also help.
U Street, D.C.: Hi Rob, thanks for chatting. There is a short bit at the end of the article saying that some lifestyle interventions are also effective. Can you comment more on this? I imagine that for people who are willing to make adjustments, changing lifestyle is a much less dangerous antidote than committing to a lifetime of pills. What type of lifestyle changes would be effective? Thank you.
Rob Stein: Losing weight and increasing exercise both also seem to reduce inflammation in the body, and have been clearly shown to reduce the risk for heart attacks and strokes (among other things). Everyone agrees that's the first thing everyone should try, and what people should do even if they do end up taking statins.
Laurel, Md.: For those of us already on statins for high cholesterol, is there any advantage in getting a C-reactive protein test? If the test were positive, would antibiotic treatment be beneficial?
Rob Stein: You might want to talk to your doctor about getting the test anyway to see what your hsCRP level is. Antibiotics would not be prescribed, but your doctor might consider changing your dose or trying another statin if your CRP is high.
Bethesda, Md.: Just to make sure I understand: the statins successfully reduced cholesterol levels, thus reducing risk. However, they had little effect on the number of heart attacks. Is that right?
Rob Stein: Sorry if that was confusing. The statins DID have a clear impact on heart attacks, reducing the actual number of heart attacks and the risk. The actual numbers were relatively small -- there were 68 heart attacks among those taking the placebo and 31 among those taking the statin. But that translates into a 54 percent reduction in relative risk.
San Diego, Calif.: Has there been a study of the benefit of statins for a group with no known risk factors? Or to a group of people with low CRP rather than high? What were the results?
Rob Stein: This study focused on people who had what were considered high hsCRP levels -- 2 or above. But the reduced risk was found even among those with no other risk factors beyond an elevated CRP level.
Shepherdstown, W.Va.: Do people with high cholesterol also have high CRP readings?
Rob Stein: Sometimes, but not always.
Washington, D.C.: I am skeptical about the researchers' conclusion that the benefits seen in the study participants who were treated with statins were attributable to the reduction in CRP levels. The statins also dramatically reduced LDL-cholesterol levels (from about 110 -"normal"] to about 55) -- isn't it plausible that the benefit of statin treatment was just an extension of what's already been proven regarding cholesterol-lowering (i.e., the lower, the better)?
Rob Stein: That's a good question. It's unclear from this study how much of the benefit was from reducing cholesterol even lower than what current guidelines calls for, and how much was from reducing CRP. No one really knows the answer to that crucial question. But because the magnitude of the benefit was so strong, many of the researchers I interviewed said they suspected that it was probably the combination of the two.
Maryland: If the guidelines are revised, are they going to include any recommendations about isolating and treating the cause of inflammation, rather than just prescribing medicine for the symptom? A lot of factors can raise CRP, including periodontal disease, which many people don't even know they have and medical doctors don't normally examine for it. Prescribing statins for these people won't do anything to kill off the bacteria that cause the inflammation in arterial walls.
Rob Stein: Yes, there's been a fair amount of interesting research indicating that people with periodontal disease are at increased risk for heart disease and that the reason may be because of increased inflammation. That's another good reason to get prevent and treat periodontal disease (besides trying to keep your teeth).
Hood River, Ore.: Maybe I'm misunderstanding something, but why would prescribing a drug that lowers cholesterol (like Crestor) be helpful to someone who doesn't have a cholesterol problem? Wouldn't an anti-inflammatory drug be better, since this test is finding risks associated with inflammation?
Rob Stein: That's one of the interesting aspects of this area of research. Statin drugs were originally developed to lower cholesterol, and they do that. But it appears they have other effects that are also beneficial, such as lowering inflammation.
Kensington, Md.: In the past few years there has been increasing awareness that men and women can display different signs and symptoms for major health problems. Most notable in my mind is the difference between the typical symptoms of heart attacks with men typically experiencing pressure in the chest and pain shooting down the left arm heart attacks and women experiencing a wider variety of less distinguishing symptoms. What percentage of study participants were women? Were men and women looked at separately in this study? Did the study results suggest any differences in the role inflammation plays in the progression of heart disease between women and men? As a more general question, how are heart disease and heart attacks related? Does heart disease progress toward heart attacks and do you always have heart disease if you have a heart attack?
Thank you for your time.
Rob Stein: I'm really glad you asked that question. This is actually one of the first big studies to include enough women to demonstrate that statins can help them as much as men.
Heart disease sets the stage for heart attacks. Plaque builds up inside arteries supplying blood to the heart. When that plaque ruptures, blood clots can form, blocking blood to the heart and causing a heart attack (or a stroke if it's an artery supplying blood to the brain).
Silver Spring, Md.: Rob, I had to read all the way to the end of your article to find out that this study was funded by AstraZeneca, the manufacturer of Crestor, the drug used in the the study. Although AZ might not have exerted a direct influence over the results of the study, the researchers know the hand that feeds them. Basically, they are creating a whole new market by prescribing an expensive pharmaceutical product to otherwise healthy people. Anyone who is taking statins also has to get blood tests several times a year to make sure they are not developing dangerous side effects. Don't you think that a little more journalistic skepticism would have been in order here?
Rob Stein: That's a very good point. I raised that issue with everyone I interviewed. Critics who think we are already prescribing too many drugs argued that this study is just another attempt by a drug company to encourage more people to start using prescription medications. But many other leading experts I interviewed for the study who had nothing to do with the study said it was a very well designed, well conducted study and that the funding source does not appear to have any influence over how the study was conducted or how the results were interpreted. That said, there's still a lot of debate about whether lots of people should start taking statins based on these findings alone.
Potomac, Md.: Does the finding transfer to all Statins -- what about the generic form?
Rob Stein: Other statins, including those that are available in generic form, also do reduce inflammation. What remains unclear is whether they would produce the same magnitude of benefit as that found in this study. They might, but no one will know for sure unless they do another study like this one using another statin.
Herndon, Va.: I'm taking a "Mevecor" equivalent for my high cholesterol -- is that in the Statin "family"?
Rob Stein: Yes, that is a statin.
Washington, D.C.: I am 27 years old and obese. I have been for most of my life. How significant is age in determining inflammation?
Rob Stein: No one is suggesting routine CRP testing for everyone, but they are suggesting that CRP testing could be used to help evaluate a person's risk for heart disease along with other traditional risk factors, such as cholesterol, weight, age etc. Someone who has been obese throughout their life should certainly be consulting with their doctor about how to reduce their risk for heart disease, no matter what their age.
Washington, D.C.: Given how powerful statin drugs are, I would like to see the results of this study duplicated by another group of researchers, specifically one NOT funded by a statin manufacturer. How likely do you think it is that NIH or another public group would fund a second study? Thanks.
Rob Stein: That's a good question. A study like this is very expensive, and in fact the researchers had first approached the NIH for funding.
Anaheim, Calif.: This is truly pathetic. As a Critical Care RN for over 35 years, this appears to be one more attempt for drug companies to push another pill for a non-disease, invented disease, or a disease you "might" get. These medications are not without serious health risks, to say nothing of serious cost. (Yet another method to inflate the costs of healthcare.) Physicians and patients also need to think way outside the box before writing an Rx for medications. In the healthcare (and I use that term lightly,) environment of today ANY prescription medication taken, must be reported when applying for individual health insurance. With job losses and skyrocketing health costs to the people, more and more people will be attempting to obtain care through private companies. Here is a word of warning. A statin or the like, is in most cases, a red flag for insurance companies, and can mean an automatic refusal for insurance. So now you have a healthy individual taking a statin for "prevention" finding themselves unable to obtain insurance. For every insurance company this is a red flag, statin equals risk. So before one writes that Rx or fills that Rx, think outside the box. What are the possible consequences, except more profit for drug companies.
Rob Stein: Thanks very much for your comment. This is definitely one of the big concerns and issues raised by this study: What is the risk-benefit analysis? That's something expert panels will be considering when they consider incorporating these findings into officials guidelines to doctors.
Rob Stein: Wow -- that hour certainly flew by. Thanks so much for all your great questions, and my apologies to those that I wasn't able to get to. This is certainly generating a lot of interest and debate, and I'm sure it's a topic we'll be returning to. Thanks again.
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