Do Statins Actually Work?Journal Club Explores Recent Paper

[Music] [Music] hi welcome to another episode of talking with docs i'm dr paul zalzel i'm dr redwing it's a journal club dr winnie yes very interesting journal that is hot off the press it actually didn't really just come out to be honest i have an article that is lukewarm tepid it's august and it came out in march okay i have an article that is now room temperature was once hot then warm now it doesn't matter don't worry about the temperature of the article okay it's a really interesting article okay from jama jama okay journal of the american medical association jama which i like to read in my pajamas i've said before evaluating the association between low density lipoprotein cholesterol reduction and relative and absolute effects of statin treatment a systematic uh review and meta analysis that's right so ldls and statins not a very controversial topic it's controversial okay but it's a good article it is a scientific article that was in jama so we thought we would just do a little quick review of it yes and i know we also have another little video that talks about absolute and relative risk reduction and number needed to treat what in med analysis that might be worth looking at if you're interested in this kind of terminology yeah because there that kind of terminology appears a lot obviously in scientific studies okay so so here it is this is a this this is a controversial topic as you mentioned because um statins are a class of medication that are used to reduce cholesterol specifically ldl cholesterol which is thought to play a major role in the development of atherosclerosis right which is plaques in the arteries which can lead to heart attacks stroke and death right so the short version is our bodies make the majority of our cholesterol and then an enzyme called hmg coa reductase is critical it actually is the rate limiting step in cholesterol formation and statins stop it they are hmg coa reductase inhibitors so they stop the production of cholesterol to lower the cholesterol so i think most everyone would agree that statins are very effective at reducing your cholesterol they reduce the production of cholesterol that's not really a negotiable thing measure it in a blood test right measure a blood test but now why are two orthopedic surgeons what do we care so much about statins for well a we have patients that have heart attacks and strokes that's the first thing we care about healthy living that's why we replace people's joints they get better lives the side effects of statins include muscle pains and orthopedic surgeons were in the business of treating muscle aches and pains and see this orthopedic surgeon has uh high cholesterol and funny about bee is that i have had patients before where they've come with a musculoskeletal complaint and i've done x-rays and examined i'm like this doesn't make sense and then we figured out together and i asked him is he going to stay and then yeah i just started i'm like did your symptoms coincide at all and they're like yeah so like this is a real thing get off staten island your muscle pain goes away yes no don't get off your stat and talk about it with your family uh yeah critical actually do not make a decision based on this video yeah use it to empower yourself to talk to your family and personal experience my i mean my lipid profile was like that bad report card in grade five you didn't want to bring home to your parents yep uh did you ever have one of those i didn't i always had good reporters but i had two older sisters that always had better report cards yeah it was tough that's sorry they were pretty good report cards yeah um anyway so do you want to talk about that at some point okay so i was on i am on a stat okay so that's why this article for those reasons we're interested in this article okay so this actually is a meta-analysis like we talked about so the short answer is it pools a whole bunch of similar studies to try to get more reliable evidence um with bigger numbers and longer follow-ups so what they did is someone did a systematic review where they looked through all of the research papers from 1987 to i think june of 2021 so 34 years to find high quality randomized controlled trials that had a minimum of two year follow-up comparing the use of statins versus placebos uh in the not only the lowering of cholesterol but really looking at outcomes that included all-cause mortality heart attacks and strokes those are the end points and points that they were looking for because some studies look at all sorts of endpoints so they chose these three and how many studies did they find in 34 years of research paul okay well they initially they found like 175 or something like that but when they did their systematic review and went through it to say which are good articles that are worth looking into more detail right they came up with 21. right because the best meta-analysis is that one that has articles that are or studies that are very very very similar because heterogeneity or when it's slightly different reduces the reliability of your findings right and they talk about that in this study sure so 21 articles so they pooled all their data to try and see if taking the statin medication reduces the chance of all-cause mortality that you're dying from anything having a heart attack and having a stroke then the secondary analysis they did was to say well if your cholesterol is lowered by these statin medications can we see the a relationship between the lowering of the cholesterol and these outcomes okay so first still following is just too confusing rewind it's a lot okay so let's first start with the relative risk reduction so this is a term that compares the difference in the outcome of the treaty group with the non-treaty group so what they found was the relative risk reduction for all-cause mortality was nine percent for heart attack was 29 percent and for stroke was 14 how did you memorize those that's well done no i would have to refer that but anyway bottom line is those relative risk reductions look good yes right that made me feel great i'm on a statin i feel good because i've reduced my risk by 19 and 12 yeah whatever good numbers yeah okay and then they looked a little closer at what's called the absolute risk reduction so essentially the actual number of people who had reduced events and that number went down a little bit so it went to 0.8 for all-cause mortality 1.3 for heart attack and 2.4 for stroke so the absolute risk reduction is not that great modest as they described it yes now what what that means is that the number of people you need to treat with the statin medication is closely related to the absolute risk reduction and not the relative risk reduction so it turns out you have to treat like i don't know 70 people one of them i think it said 77 people had to be on statins for 4.4 years to stop one heart attack so that is not as uh engaging in number as those initial relative risk reductions right so the criticism too was that a lot of the previous studies didn't present the absolute risk reduction they just presented the relative risk reduction right which can be misleading because then patients and prescribers might think well the effect is so great because the relative risk reduction is so high i want to reduce my heart attack risk by 30 yeah everybody does but the absolute risk reduction so really the chances how much was the chance of a heart attack reduced was less than one percent yeah um so that's why it's important to look at both those risk reductions when making a decision to treat someone with something right so and so so what some of the conclusions because obviously um there's uh a lot of discussion about this paper and the authors themselves said listen the studies weren't all exactly the same so there is a little bit of what's called heterogeneity in the data so that increases the potential for the results to not be quite as definitive as they would claim and they acknowledge this yeah and other people certainly brought this up as well and the other thing they did well they looked at their you know their secondary analysis where they said well let's look at the ldl numbers right okay those low density lipoprotein cholesterol numbers right and let's see the ones that were reduced on the statin let's see if we can find a correlation between the reduction of ldl and those endpoints of all cause mortality heart attack and stroke and they couldn't show a very good correlation so it doesn't mean there isn't a correlation right but they couldn't show it from the data they have and so you would think if there was a strong correlation they'd be able to show it but they they couldn't show a significant correlation a strong or significant correlation and what this may mean like we talked about in some of our other videos particularly one about absolute relative risk reduction is that the other associated risk factors and the prevalence of the disease predict the effect of the treatment so there are certain populations that we can almost certainly say have significant benefit and those numbers would be a lot higher if we treated them with statins whereas someone that maybe is healthy has no family history has no other risk factors eats healthy exercises but has elevated ldl maybe that person is someone who's not going to benefit from a statin and in the comments a lot of people say well listen i have high ldl but i've had a calcium score and i've had an angiogram and everything's perfect maybe i don't need to take stem and maybe you don't that's a that's what we're trying to tease out is who is the group that benefits the most from this type of medication okay and so from this study i got four main points to share with everybody one there's a difference between absolute risk reduction and relative risk reduction and and in the case of the statins that that difference is significant so you should keep that in mind two they couldn't really show a correlation between the number the cholesterol number and the outcomes uh in this meta-analysis three uh all those studies that are out there are very heterogeneous as dr weaning said so they're looking at different outcomes and different endpoints it's not very well organized from one study to the other where everyone's looking for the same thing it makes it difficult to do a meta-analysis and four a lot of those studies that are out there that that people use to say yes we should be putting people on statins have composite end points which include things like oh did you have a cardiac revascularization procedure were you hospitalized those are softer endpoints um as opposed to death heart attack stroke right so those are the four main take-home messages i got from this so what should what should you do if you're on a statin keep taking it don't stop your stand based on what you're seeing i say but what should you do is talk to your family doc your care provider about it before going on a statin or if you're honest at and you have concerns really you want to discuss it with them we will always advocate healthy eating and exercise for to be honest almost any medical condition to start some medication is necessary some medication is very successful at treating and preventing disease oh yeah like it's undeniable as much as people loathe big pharmaceuticals oh yeah pharmaceutical companies do improve people's lives and save people's lives they are not perfect or not infallible and neither are doctors so um everything is with the grain salt not too much salts we want your blood pressure to go up um but i mean i'm in i might be in the same boat as you are with high cholesterol i'm on a statin personally and i'm going to continue taking it but i am going to discuss it with my family doctor and this is an evolving area of research so what causes a plaque is not just cholesterol it's inflammation it's insulin resistance it's so many other factors that it's hardest to tease one out and i think historically it's maybe been oversimplified and that's what's probably got us here what's up all right journal club club now you feel educated if you like this video please like it subscribe to our channel and share it with someone who you know is honest at and may be interested in it yeah and remember you are in charge of your own health we'll see you next time

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Id: TypwmEuP4U4

Length: 12min 6sec (726 seconds)

Published: Fri Sep 02 2022