Statins, heart disease, and risk - a conversation

What gives? How can someone with high blood cholesterol levels for 30+ years end up with clean arteries, if indeed there is any causation between blood cholesterol levels and plaque accumulation. ... Perhaps actual blood cholesterol levels have no cause of heart disease on their own a-priori. And, if any of these crazy hypotheses are true, then how can a health system prescribe drugs like statins so casually and routinely to anyone with cholesterol over 230? This is particularly true, when the long term side effects of such drugs must still be unknown.

Lots of questions -- some scientific, some health-plan political... But mainly I am looking for just straight talk on this whole cholesterol/heart disease issue.

You ask a lot of good questions. Let me paraphrase them for ease of presentation.

1. How do statins help in heart disease - through lowering the cholesterol level or some other mechanism?

It's not clear - this is one of those topics where the pendulum of the literature swings back and forth, and I can't say that I've followed every swing. Some hold that statins lower cholesterol, cholesterol causes heart disease, and that's it (though all the details of what the worst cholesterol particles actually are, and how they work their deadly magic, are yet to be fully worked out). Others think that statins are "pleotropic" - i.e. they work in multiple ways, e.g. by reducing inflammation.

2. How could you have high cholesterol and still have clean coronaries?

It's quite possible. I would imagine pretty common. That's why one of the biggest statin-related controversies hasn't really hit the lay press yet. It's all about when to give the medicines. Should everyone be on a statin if their cholesterol is above a certain level ("treat to target," or what I think of as the "statin in the water" approach), or should a statin be used only if a patient's risk of coronary artery disease is above a certain level ("tailored treatment")? A recent study in the Annals of Internal Medicine supports the latter, but no one really does this yet since the guidelines of the major doctor groups favor the former.

3. How do I know if I need to take medicine for cholesterol?

One way to think of it is this: statins lead to a reduced risk of coronary artery disease. Great. But this only matters really if your ABSOLUTE RISK, before statins, is something that you, or your doctor, are concerned about. If your 10-year risk of heart disease is 1%, and the statin reduces it to 0.1%, that's a 90% risk reduction, but maybe you don't care about a 1% risk. (I might not.) One way to calculate your risk is the Framingham risk calculator.

4, Do clean coronary arteries on a coronary CT scan (i.e. a low calcium score) mean I can't have blockages in the heart arteries?

No.

Can health care act as an economic stimulus?

I'm scholar Googling and can't find anything. I don't know what the Obama Administration's argument is supporting their inclusion of comparative effectiveness research in the stimulus bill. Obviously I think CER is great a priori, as are EHRs, but neither save money in the short run. Do they stimulate the economy? Beats me - not my field - but I suppose in the sense of creating jobs, sure. (Funding research supports researchers, who buy bread, gasoline, and electricity just like everyone else.)

Note that this is separate from whether prevention and CER give good value for the dollar. Stephen Woolf claims unsurprisingly that they do, writing recently in JAMA. But the real point of his article is this: if you're going to ask whether prevention is worth the cost, you have to ask also whether (say) CTs, MRIs, and the whole whizz-bangery of technologized medicine is worth the cost too:

Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings. Whether those services are preventive or otherwise is not the point; what matters is prioritizing services that produce the greatest health benefits for the dollars spent. ... As a matter of economic security and ethics, it is inappropriate to debate the economic value of prevention while excusing the rest of medical care from such scrutiny.

A penny of prevention is worth a pound of cure?

I wish Obama all the best, and I'm excited that health care reform is being contemplated as one of the first orders of business after the stimulus package is passed. Prevention is being touted as a big healthcare money saver.

But prevention of what?

1. Prostate cancer by PSA screening. (Whoops, early detection doesn't decrease mortality.)
2. Breast cancer by self-exam. (Whoops, ditto. Mammograms work, though.)
3. Colon cancer by colonoscopy. (Right-sided cancer might not be caught by colonoscopy.)
4. Pneumonia by vaccination. (Whoops, maybe not - except in high-risk groups.)
5. Heart disease in women by estrogen replacement therapy. (We know how that turned out.)
6. Cancer by vitamin ingestion. (Whoops again.)

So not only is prevention very unlikely to save significant healthcare money, but we have to make sure we're actually preventing what we set out to prevent.