First a disclaimer: I’m a psychiatrist, not a cardiologist, but I’ve followed with personal interest the discussions about calculating cardiac risk and indications for statin treatment. Risk is an interesting word, because risk is about populations; it loses the individual.
And it seems that statin treatment has taken on a bit of stigma — something we’re used to in psychiatry — now you can eat your cake and have low cholesterol, too! The articles are all careful to point out that it’s preferable to lower cholesterol with lifestyle changes, that statins are for when such changes fail or for those who are too lazy and indulgent to even try exercise and dietary modification.
My brother did everything right. His cholesterol was high when he was younger, and he worried a statin would have side effects, so he changed his diet. He exercised regularly. His HDL remained low, so he exercised more and his HDL rose.
At one office visit, he had mild hypertension, so he purchased a blood pressure cuff and recorded his blood pressure daily, confirming that the elevated reading had been an abberation. As an economist, he loved data. He had a negative stress test at age 50. He was never a smoker. Last year, his blood sugar was elevated to 104, so even though he was not overweight, he dropped down to what he weighed in high school. With lifestyle changes, my brother was able to manipulate his lab values, blood pressure, and weight, to avoid taking medications, and to achieve a low risk profile. He really did everything right, and as you can imagine, it was a shock when at age 59, in seemingly good health, he died of asymptomatic, severe calcified coronary artery disease. The only clue that such a thing could happen was that our father had died of a heart attack only hours after his initial presentation of chest pain while shoveling the snow at the age of 40, decades before statins existed.
At his last exam, my brother’s doctor had suggested he have a calcium score — my brother elected to hold off on this. After all, he was feeling well and was exercising daily with no symptoms. “Perhaps I should have insisted,” his doctor told me.
Calcium scoring improves risk prediction in people without indications for statin therapy, according to a 2011 study in Atherosclerosis, “Coronary artery calcium score improves cardiovascular risk prediction in persons without indication for statin therapy.”
Still, the authors concluded, “… reclassification to the high risk category and overall event rates seem too low to justify liberal CAC testing in all these individuals.”
Given that it my brother who died, I feel differently and I’m left to wonder if such screening might have saved my brother’s life. Insurance companies, I’m now all too aware, don’t agree. After his death, I had a 64 slice CT with calcium scoring. Aetna, my health insurer, later informed me that this exam is considered “experimental and investigational” in asymptomatic individuals, and as such it was not approved for coverage, even though the procedure required no pre-authorization and even though my genetics may be much different from the population that has been studied.
I’m not sure how a patient (me), the two physicians who recommended the test, the imaging facility that verified coverage, were supposed to know that Aetna would not agree with the clinical indication.
People die of heart disease with the most aggressive of interventions. There are no guarantees and both the diagnostic procedures and the treatments come with their own risks. The decision to recommend a statin or to perform a diagnostic test can be a life or death call, and issues of risk need to be considered in the context of the individual, not a population or an imperfect formula. Even in the best of worlds, the numbers plugged in to risk calculators — total cholesterol, HDL cholesterol, and systolic blood pressure — are labile and subject to change. A person at high risk one day may be at lower risk another day.
The guidelines also place a strong emphasis on “patient preference,” when even the most educated of patients may not realize what is at stake — their life. And patient preference is often guided by how strongly their physician emphasizes the risks versus the benefits; we think of these discussion as informed consent, but they often are more about sales technique.
And just to be clear, there’s more to coronary artery disease than self-discipline and lifestyle choices. It may be that for some individuals, the focus on a healthy habits and optimal numbers becomes a distraction that moves us away from using more aggressive diagnostic and treatment options in people who might benefit from them.
Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.
