Dear Dr. Roach: For 10 years, my daughter has refused statins (due to cholesterol level) on grounds that women were not a part of the studies recommending statins and that heart disease manifests differently in women. Her daily eating and exercise are stellar. After a decade, her female internal medicine doctor confessed that she, too, doesn’t take statins for the same reason, although she feels it necessary to prescribe them to patients whose cholesterol warrants it. (Is it fear of a lawsuit, or does the continuing education of all doctors come from Big Pharma?)
I have no family history of heart disease (both parents lived into their 90s), but my cholesterol level warranted seeing a cardiologist. He says at my age (84) family history doesn’t apply, and my cholesterol warrants taking a statin.
It makes no sense to pay this doctor and not take his advice, but every day when I swallow 20 mg of atorvastatin, I wonder if it’s going to cause a problem rather than solve one.
Can you address the gender objection to statins?
Women have different hearts from men and often have different symptoms of heart disease, so it makes sense to consider whether the same drug effective in men isn’t effective in women. It is certainly true that women are prescribed statins less than men are, but whether that is because women are being undertreated has been the subject of debate.
Historically, women have been underrepresented in studies on heart disease. Of 27 trials looking at effectiveness of statins in treating and preventing heart disease, only 27% of the subjects have been women. However, that still means that almost 50,000 women were studied, and statins were found to reduce relative risk just as effectively in women as they do in men. However, because women have a lower absolute risk than men do, it has been harder to prove effectiveness until a 2015 study looked specifically at this issue.
I don’t have enough information to say whether you or your daughter are appropriate for statin therapy. Age and sex, blood pressure and cholesterol numbers, smoking history, diabetes, and other risk factors including diet and exercise all go into the estimate of a woman’s risk for heart disease.
I occasionally see women who are inappropriately treated with statins (because their risk is so low), but more commonly, I see women who would greatly benefit from statins and are not being given the medication that could help them. The decision starts with estimating risk (by using a tool such as tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/), explaining the benefits and potential harms of statins, and helping your patient make an informed decision. Decisions should be based on sound science, not pharmaceutical advertising and not unwarranted fears.
The data are clear that these medicines, when used wisely, are helpful. In women who have blockages in their hearts, statins should be prescribed (unless there is a good reason not to). For women without heart disease, the decision must be individualized, and sometimes additional testing, such as blood testing or imaging is helpful when it isn’t clear what to do.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu