Should doctors prescribe pharmaceuticals to patients who have heart disease. Statins and ACE inhibitors are frequently prescribed to patients with cardiovascular problems. These medications have been shown to decrease the risk of heart attack in clinical trials, but could they actually increase the risk of a heart attack in the real world?
The answer is yes if taking the drugs changes behavior. Without any pharmaceutical treatment, patients with a family history of a heart attack may decide to exercise more and eat healthier. Once the patient starts taking the pharmaceuticals, however, this may give them less of incentive to take care of themselves. The drug can give them an excuse to engage in an unhealthy lifestyle.
“Yeah, I’m still smoking and eating philly cheesesteaks for breakfast, but I’m taking a statin so I’ll be fine.” It is true that clinically statins reduce the risk of heart attack. If heart medications also produce a sense of false security and adversely affect patient lifestyle behaviors, then prescribing these medications may actually be counterproductive.
This is very interesting and logical, but I don’t believe that people with heart disease and are also prescribed drugs would maintain risky behaviors (although smoking is a tough one, being chemically addictive and all). I believe that knowing they have heart disease and being willing to get regularly checked up enough to be prescribed heart drugs is for most part a reflection of a change in behavior towards healthier habits.
Nonetheless, I definitely think it’s important that patients understand exactly what benefits have been shown for these heart drugs, because many have argued that although they have shown clinically significant outcomes compared to a control group, the absolute reduction in risk is still low. For example, the fine print in Lipitor ads qualify a reported 36% reduction in risk by saying “That means in a large clinical study, 3% of patients taking a sugar pill or placebo have a heart attack compared to 2% of patients taking Lipitor” over a 3.5 yr period.
Cost-effectiveness experts like to use the statistic NNT, the “number needed to treat” for one patient to experience a benefit. For standard antibiotics, the NNT is evident, at about 1.1 (if 11 people are given a drug, 10 will benefit). But for people with heart disease taking statins, the NNT has been pegged at 100:1, and even worse, 250:1 for statin patients with lower risk. I think if people really comprehended these numbers, they may take their statin use with a grain of salt, knowing that it’s a rather weak safety-net.
Based on the early statin trials-WOSCOPS, AFCAPS, SSSS, etc. the risk reduction is on the order of 50% event rate reduction over a ten year period. The longer the time period under consideration, the smaller the NNT for a chronic treatment. Thus the expected benefit for an individual depends heavily on baseline risk and the willingness and ability to persevere with a treatment over a long period. Based on the Framingham data, if one’s risk of an event ( a heart attack, sudden death, or need for bypass surgery) is 18% over the ten year period, considered a moderate to high risk in the Framingham scheme, going to the expense and effort to reduce it to 9% may be entirely reasonable. If the baseline risk is 1%, reducing it to 0.5% is clearly not. A treatment’s value is admittedly in the eye of the beholder. Some especially fussy folks might think going from 3 to 1.5% worthwhile and the gambling sort might want to take his chances regardless of risk status.
Wouldn’t that effect- slacking on health behavior because of treament- have been seen in the clinical trials as much as in real life?
We need a trial! In one pool are people explicitly prescribed simvastatin, on the other are people who are told they are in a clinical trial and may be receiving a placebo but who are really all receiving simvastatin.