The Daily Dose 1/8/09

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Dear Dr. Spence,
I recently read in the paper that a new study suggests that all patients may benefit from cholesterol lowering medications regardless of any individual risk. Should I be taking zocor or lipitor or is this all media hype?
Signed,
Statin-less

Dear Statin-less,
The study you are referring to is the JUPITER trial, recently published in the New England Journal of Medicine. The study involved nearly 18,000 patients and showed that giving a cholesterol lowering statin drug to seemingly healthy people with normal cholesterol levels could cut the risk of heart attack, stroke and death by nearly 50%. These findings provide the best evidence to date that a statin can reduce cholesterol and inflammation within arteries. The patients in the study had normal cholesterol but they all had elevated levels of C-reactive protein, a potential marker of artery inflammation and heart disease.
Half of the patients in the trial were given crestor; the other half received a placebo. Those in the crestor group experienced 54% fewer heart attacks, 48% fewer strokes and 20% fewer deaths – findings so impressive that the study was stopped after only two years so that those taking a placebo could be offered the study drug.
A separate analysis speculates that giving statins to everyone in the United States whose heart risk matches those in the study could prevent about 250,000 heart attacks, strokes, bypass surgeries and deaths in the next five years.
The patients in the JUPITER trial all had LDL cholesterol levels less than 130 mg/dl. Crestor significantly reduced the incidence of major cardiovascular events despite the fact that they were well below the threshold for treatment. Most would not be considered candidates for statins at all. LDL levels were less than 55 mg/dl in 50% of the study participants on crestor with 25% below 44 mg/dl. This raises the question of exactly how low LDL should be in order to prevent deleterious outcomes. Levels that low approximate those of a newborn. One could argue that anything above that level may incrementally increase risk.
Other questions remain. In an accompanying editorial in the New England Journal of Medicine, risk of cardiac events was only reduced from 1.8% in the placebo group to 0.9% in the crestor group; thus 120 patients were treated for 1.9 years to prevent one event. Is that worth it? The theoretic cost to prevent that one event may be on the order of hundreds of thousands of dollars. Would a generic medication like zocor be an equivalent substitute? As of yet, the answer is not known. Caution must be taken when interpreting the data, but it certainly deserves thought. I suspect, in one sense, these agents provide more benefit than just cholesterol lowering. Time will determine whether they should be as readily available as over the counter supplements (which some have suggested).

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.