Hanging out in doctors’ offices is not quite my cup of tea. But there I was, summoned to my internist by an email telling me I needed an ultrasound of my abdomen to rule out an aortic aneurysm, a test he would order once I came in. Having reviewed my chart, the doctor looked mystified. I had already had that test a couple of years earlier. It came back normal, and I did not need another. It turned out the electronic medical record system automatically fires off these notices to patients who are due for preventive screenings, and my email was simply the product of a glitch.
The visit was not wasted, though, at least not from his point of view. He pounced on the fact that I had, most respectfully, declined his earlier recommendation to take regular doses of cholesterol-lowering medication, and he spent a good while trying to overcome my resistance. I had tried statins before. They gave me muscle pain. Lowering the dose eased the pain but left me with a lassitude so profound it threatened to turn me into a couch potato.
A conspiracy theorist might brand this doctor a tool of Big Pharma, but that would be unfair and flat wrong. He is no quack. He is a distinguished professor of medicine at UCLA, and his recommendation rests on scientific evidence backed by the American College of Cardiology and the National Institutes of Health. He was working from an algorithm developed by no less an authority than the Mayo Clinic. Still, I can picture Big Pharma rubbing its hands together at the thought of all those prescriptions, and of hordes of older men and women starting the day by dropping a statin.
To be fair, statins do more than lower cholesterol. They also calm inflammation in the arterial wall and stabilize plaques, making them less likely to rupture.
The formula dictates that most men my age, with even a hint of one or two risk factors for heart attack or stroke, should start a statin and stay on it for the next ten years. One author of the underlying research wrote that this “represents good value for money spent, even accounting for side effects including diabetes and muscle pain.” Wait a minute. You want me to take on the risk of diabetes and muscle pain in order to lower my risk of a heart attack or stroke? Now I know how Odysseus felt, though the only life I was risking was my own.
To understand the dilemma, you have to wade into statistics. Nobody was promising me that ten years of statins would guarantee I would never have a heart attack or a stroke. What my doctor said was that 3,650 pills and north of $8,000 later, my risk would drop by 25 to 30 percent. OMG! If that were the whole story, it would almost be criminal not to pipe statins into the water supply.
Except those numbers describe relative risk. Say your risk without statins is 20 percent and your risk with them is 15 percent. That is a 25 percent change in the numbers, and that is the relative risk. The picture looks rather different in absolute terms. Twenty minus fifteen is five. That five percent is the absolute risk reduction, and it is a very different kettle of fish.
The recommendation to take statins is really a public health approach to preventing heart attacks and strokes. If a million people took statins for ten years, we would spare roughly 50,000 of them. Now we are talking. It is a bit like building toilets across rural India or rural Africa: the payoff shows up across a whole population, not necessarily in any single person.
Are there other ways to move these odds? Yes. The Mayo Clinic risk calculator gives weight to protective factors such as plenty of physical activity and a diet rich in fruits and vegetables. Lifestyle changes, losing weight and cutting back on saturated fat, lower the risk too. So once again I opted for a better quality of life, accepting the roughly five percent higher statistical chance of popping off early from a heart attack or stroke.
Five years later, at the ripe old age of 80, I was summoned back, this time by a cardiologist distressed that I still was not taking statins. After some back and forth, he talked me into a newer, more expensive version he promised would have minimal side effects. He did concede that very few studies have looked at how well statins work after the age of 75. But what have you got to lose, he said.