A statinator speaks

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After the Enhance study came out Katie Couric interviewed Dr. Steve Nissen, a statinator of renown.

Although Dr. Nissen, who is the Chairman of Cardiology at the Cleveland Clinic, is upset over the findings of the Enhance study, it hasn’t dimmed his enthusiasm for statin drugs a whit. As you watch the video, note the quotes I’ve excerpted. They demonstrate how a famous cardiologist is firmly in the grip of the lipid hypothesis despite considerable evidence that the hypothesis has been built on a very shaky foundation.

Here is the video.

Here are the excerpts:

In all the historical studies, the more you lower cholesterol, the better the outcome.

Really? What about those studies showing that very low cholesterol levels are associated with violent behavior, violent death, suicide and an increased incidence of cancer?

We have to find the right way to lower cholesterol.

Why? Where is the evidence that an elevated cholesterol does squat?

We know that lowering cholesterol with statins is highly effective at preventing heart attacks and strokes.

Do we really know that the cholesterol-lowering effects of statins reduce heart attack and stroke? Or is it something else? And since the data show that there isn’t really a reduction in all-cause mortality, aren’t we simply trading death by heart disease for death by some other cause, including side effects from the drugs?

For the moment we’ve got to stick with what we know works, and that’s the statins.

Spoken like a true statinator.

For a lot of people, even with a healthy diet and exercise, cholesterol levels are very high. And for those people, when they have sufficient risk, we give statin drugs. We have to stick with statin drugs, and patients have to stick with them, and if they stick with them for the long term, they will reduce their risk for heart attack and stroke.

One wonders what Dr. Nissen considers a healthy diet? (Note to grammarians: there is no such thing as a healthy diet. He means a healthful diet.) I doubt that he means a healthful diet as would be described by most readers of this blog. How many comments have we seen come through this blog from people who are young, in good health and have as their only lab abnormality an elevated total cholesterol who report that their doctors want them to go on statins? Are these the patients Dr. Nissen thinks have “sufficient risk”? Or does he think a total cholesterol of 210 mg/dl is a sufficient risk all by itself. I would suspect the latter. And if these patients stick with statins for the “long term” at a cost of many thousands of dollars over their lifetimes won’t they – as the data show – simply be trading their risk for heart disease and stroke for something else? Is it a worthwhile trade? The overall mortality results don’t appear to demonstrate so.

But a good statinator doesn’t let these kinds of things get him/her down. He/she simply continues to statinate without regard for the long term consequences. Which can be considerable as is shown in a new blog by Dave Dixon, one of the long-time readers of this blog. Dave’s post points out the enormous number of deaths that are caused by physician prescribed drugs.

An article in Newsweek put this into perspective. Adverse drug reactions, from “properly” prescribed drugs, are the fourth leading cause of death in the United States. According to this article, only heart disease, cancer, and stroke kill more Americans than drugs prescribed by medical doctors. Reactions to prescription drugs kill more than twice as many Americans as HIV/AIDS or suicide. Fewer die from accidents or diabetes than adverse drug reactions. It is important to point out the limitations of this study. It did not include outpatients, cases of malpractice, or instances where the drugs were not taken as directed.

And in the video above, did you note Katie saying that right now cholesterol levels are at their lowest levels ever in this country? And Dr. Nissen agreeing? If so, and if cholesterol really causes heart disease, why hasn’t the incidence of heart disease fallen in lock step? And why does Dr. Nissen maintain his belief in the lipid hypothesis?

Makes one wonder.

(Hat tip to the Alliance for Human Research Protection blog for T-shirt graphic)

Please note: I reserve the right to delete comments that are offensive or off-topic.

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21 thoughts on “A statinator speaks

  1. Hi Dr Mike,

    And you think that all this is bad! Consider: the papers here in Australia (at least on their web sites) haven’t even reported the ENHANCE results. For the Sydney Morning Herald, The Age and The Australian, it just didn’t happen. But at least I can’t find a recent Statinator booster piece in today’s SMH. That’s something, though not much.

    Michael Richards

  2. Great post as usual, Doctor. Did you notice suits are already pending against both Merck and Schering-Plough? Perhaps the legal system can shed light on the lipid hypothesis where the statinators fail. A fine point: My old Webster’s gives a definition of healthy as “3. Conducive to health; as, healthy excercise.” Seems like “healthy diet” would be OK ?

    Hey Mike–

    Perhaps lawyers can prove themselves of value after all. :-)

    As to the difference between healthful and healthy, go to this post and see the comment from John.

    Cheers–

    MRE

  3. Thanks for the insightful (as usual) comments. And thanks for the grammar correction. It’s always bugged me to hear “healthy” foods or diets. But no matter how hard you try to buck the trend, only language purists will use the correct term.

    Hi Nita–

    I know what you mean. It bugs me, too. But, trying to change grammatical errors that have crept into the language is like King Canute trying to hold back the tide. If you don’t think so, try to get people to stop using ‘hopefully’ at the start of a sentence, as in ‘hopefully, our vacation will be fun.’

    Cheers–

    MRE

  4. What about hypercholesterolemia? What is it? Is it different than “elevated” cholesterol? Can it contribute to atherosclerosis & caridoivascular diseases? Should it be treated? Would statin medication be appropriate? Confused.

    Thanks for considering.

    Hi Lynn–

    Hypercholesterolemia is indeed the same thing as elevated cholesterol. Go to the search function of this blog and type in ‘lipid hypothesis’ and you can find all my thoughts on the subject. Then use the search function and look for ‘statins’ to see my feelings about those drugs.

    Cheers–

    MRE

  5. Hi Dr. Mike. Thanks for the link.

    Wasn’t the 36% risk reduction mentioned in the story he best case, shown by a single study? I can’t remember. At least CBS actually explained things in terms of absolute risk.

    I like Nissen’s comment about having the “totality of the evidence about drug effects.” Maybe he should consider the totality of the evidence about the cause of the disease in the first place. Everybody so stuck on treating symptoms, they begin to believe that the symptom is the disease. It’s like giving somebody a decongestant and claiming that you’ve cured their cold. It is certainly the case with the lipid hypothesis, and why there is so much confusion over the Enhance results. If lowering cholesterol is good, then lowering it more is better, right? Let’s just add Enhance to the ever-growing list of lipid hypothesis “paradoxes”.

    I remember some idiot on the news saying something to the effect that “your cholesterol can’t be too low.” Yikes. Maybe his revolutionary treatment for high serum cholesterol will be to drain patients of all their blood. At least it’s cheaper than taking statins for the rest of your life.

    Hey Dave–

    I can’t begin to tell you how many times I’ve heard the your-cholesterol-can’t-be-too-low statement. And almost always from people who should know better.

    I think you’re right about the 36 percent, but I can’t bring myself to watch the video again to check.

    Cheers–

    MRE

  6. Nissen is a powerful guy in the industry. Nissen also worked on a drug called ETC-216, made by the company Esperion Therapeutics in Ann Arbor. ETC-216 was a synthetic version of good cholesterol. Dr. Nissen did an IVUS study on 47 people and claimed ETC-216 reversed plaque by 4 percent in 5 weeks. His comments were the catalyst for Esperion’s purchase by Pfizer for $1.3 billion. Some of the founders of Esperion are still hanging around Ann Arbor, although Pfizer is closing down its mammoth research facility there. Don’t have a clue what became of ETC-216.

  7. Others grammatical goofs:

    Using “momentarily” when meaning “in a moment”.

    Using “dove” instead of “dived”. (The fact that dived was the proper term was drummed into my little 8th grade brain, and I still shudder when I hear “dove”, although it is now in the dictionary.)

    And “pled” guilty for “pleaded” guilty.

    Sigh. Language always evolves downward.

    It’s a variant of Grisham’s Law. In this case, bad grammar drives out good.

    Cheers–

    MRE

  8. Nita, you’re young. “To dive” was considered an irregular or “strong” verb, and dove as its past participle was correct for a couple hundred years at least.

    “Now in the dictionary?” Please look the verb up in a nineteenth century edition of any American dictionary or the OED.

    I’ve noticed that several past participles have been changed, like “lit” to “lighted”, “spelt” is now “spelled”, “strove” is now “strived”, etc. You’d be very surprised at how much has been systematically changed if you had a chance to peek at my fourth grade grammar book!

    http://en.wikipedia.org/wiki/English_irregular_verbs

    I have also noticed that the L A Times and the Chicago Sun Times are using “milleniums” instead of “millenia”–something that annoys me to no end! It’s one candelabrum, two candelabra, one millenium, two millenia…Yeeeeesh!

    There seems to be an effort by unnamed institutions to make English spelling and conjugation more regular–I’m not sure this helps the language.

    Hey LC–

    I don’t think it helps the language at all.

    And my copy of the OED lists both ‘dived’ and ‘dove’ as correct for the past tense of dive, but add the following sentence at the end of the entry: “Careful writers use ‘dived’ rather than ‘dove’ in the past tense.”

    Cheers–

    MRE

  9. I have to mention that it’s Gresham’s Law, as I wish my intro macroeconomics students would remember…

    That’s what I thought I wrote, but when I went back to check, alas, I found it to be Grisham, like the lawyer turned writer, not Gresham, the financier.

    Thanks for the correction.

    Cheers–

    MRE

  10. “comprised of”

    “begging the question” to mean inviting the question.

    But you know, we aren’t the French. Our language is changing as it always has. My mom used to complain about proven instead of proved, but both are now correct.

    Correct to whom?

    Cheers–

    MRE

  11. Talk about bias! That’s just telling me that I would be “advised” to employ the usage they have decided to instigate. You would have to look at what OED edition you have, Dr Mike, as I suspect it’s recent. If you look at nineteenth and early twentieth editions, you would find that the correct usage is “dove” and that “dived” is either not entered at all, or entered with some warning that it’s incorrect i.e. uneducated usage.

    I made the mistake of quoting not the OED, but the Oxford American Dictionary. Mine is the 1979 edition.

    When I looked it up in the real OED, I found the following:

    Pa. t. dived, (N. Amer. & dial.) dove.

    Which I assume means that the correct usage (at least as deemed by the venerable OED) is ‘dived,’ whereas the North American usage or dialectal usage is ‘dove.’ To illustrate the usage, there were six quotations ranging from Shakespeare to G.B. Shaw using the past tense of dive, and all used ‘dived,’ not ‘dove.’ If it’s ‘dived’ for Shakespeare and Johnson, then it’s ‘dived’ for me. You, of course, can say it however you like. Everyone will know what you mean.

    Cheers–

    MRE

  12. Healthy vs. healthful, redux
    I get your point but “healthy” has long been used to mean “healthful”. My Webster’s New Collegiate is the 6th addition published in the 1960s. A brief note on the subject can be found here: http://www.bartleby.com/64/C003/0156.html
    The suffix (-ful) is an unnecessary affectation that only makes English harder to learn, especially as a second language.

    I get your point. And both my venerable OED and my Oxford American Dictionary list healthy as a synonym for healthful, although it’s not the first choice. I suppose both are correct, but I prefer the precision (I wouldn’t call it an affectation) of healthful when I mean producing good health as compared to healthy which can mean both a state and and an adjective.

    Cheers–

    MRE

  13. You guys are arguing while the Titanic is sinking. Have you forgotten the primary purpose of communication? It’s to speak so as to be understood. Like the late great admiral (whose name I forget :-)) roared. ” If b-u-r-d doesn’t spell bird, what the hay does it spell?” I’d have understood him if he spoke it. Now, when it comes to prescription medicines, I expect correct spelling and legibility, 2 things that are sadly lacking. With that said, he dove back into the fray! :-)

    What else can one do while the Titanic is sinking.

    Cheers–

    MRE

  14. All languages change and evolve due to passage of time and geographical dispersion. In written languages there is descriptive grammar (what people actually say at any given time in a given place) and prescriptive grammar (the rules dictating what one is supposed to say, followed only by people of a certain educational level and social register–and those rules change, too). Our mass communication systems slow down the rate of linguistic change, but every language changes over time. English as it was spoken a thousand years ago now has to be learned by us as if it is a foreign language. We can’t stop “healthful” from disappearing nor can we prevent “healthy” from taking its place. Regarding the use of “millenniums,” it’s also a feature of language that irregularities regularize, and since we have almost no one left anymore who knows Latin, it’s to be expected that we will not retain Latin neuter plural endings in lieu of the predominate English “s” plural pattern. I teach ecclesiastical Latin, and the Latin that St. Jerome used in the Vulgate Bible was going through these exact same processes in the early 5th c. A.D. I constantly discover grammatical structures that are not “supposed” to be that way according to all the grammar books written for classical Latin. I used to be a totally flaming “prescriptivist,” but the more I’ve studied languages and historical linguistics, the less bent out of shape I’ve become about “bad” grammar. Today’s good grammar was yesterday’s bad grammar and today’s acceptable spelling was yesterday’s wrong spelling. All we can do is write and speak the best we can as educated people in our time and place.

    Hi ethyl d–

    In my head I agree with you, but at heart I guess I’m a “prescriptivist.” There are those who think that the sole purpose of language is as a tool for communication, and as long as the message gets communicated, the method isn’t important. In other words, it’s just as effective to point at something and grunt as it is to say, would you please hand me that. Both get the message across, but one is so much more…I don’t know what.

    Cheers–

    MRE

  15. Great post, but grammar-policing only detracts from the legitimate points you are making. Besides, “healthy diet” is grammatically correct. :)

    From http://dictionary.reference.com/browse/healthy :

    ‘ Usage Note: The distinction in meaning between healthy (“possessing good health”) and healthful (“conducive to good health”) was ascribed to the two terms only as late as the 1880s. This distinction, though tenaciously supported by some critics, is belied by citational evidence—healthy has been used to mean “healthful” since the 16th century. Use of healthy in this sense is to be found in the works of many distinguished writers, with this example from John Locke being typical: “Gardening . . . and working in wood, are fit and healthy recreations for a man of study or business.” Therefore, both healthy and healthful are correct in these contexts: a healthy climate, a healthful climate; a healthful diet, a healthy diet.’

    Hi Dave–

    I agree (reluctantly) that it is correct. But is it the preferred usage. I don’t think so. I’ll continue to use ‘healthful’ when I’m talking about something bringing or causing good health and ‘healthy’ when I’m talking about a state. And I won’t take anyone to task for using the terms interchangeably as long as no one takes me to task for using an affectation when I use the term ‘healthful.’

    Cheers–

    MRE

  16. As English is a mingling of the worst parts of two fairly logical languages, combined with a bunch of odds and ends from a number of others, it should evolve to be more user friendly. There, I said it. Everyone over 40 can get mad. Just because you learned it in grammar school doesn’t mean it’s worth retaining. And the complexities that make english hard to learn maybe don’t have a place over the next couple of centuries. What is more important? The preservation of odd things that experts can harp over and make a career of (see: William Saffire). Or, the continuing evolution of the language into a more useable and useful format. I don’t see a need to keep the folks who trade in preserving the “common” wisdom on language use anymore than continuing the employment of statinators who preserve the “common” wisdom of low cholesterol = good health.

    No response needed. Please post under the new guidelines.

  17. Watching this idiot repeat endlessly that the best treatment for heart disease prevention is statins and the new exciting drugs which are coming (on the PBS special about heart disease last night) raised my blood pressure. Fortunately, it went down after I took my magnesium citrate.

  18. I am a newcomer this forum & have found the information & discussions about cholesterol etc very interesting. However would it be possible to explain the different ways of measuring cholesterol & triglycerides. In the UK the measurements are different than those used in this forum. For example my recent fasting cholesterol was total 4.5 with HDL of 1.5 & LDL of 2.4. My triglyceride measurement was 0.7. How do these compare to the figures quoted in the forum?

    Hi Vic–

    Europe uses SI (Systeme International) units, which are mmol/l whereas the United States uses the traditional units of mg/dl.

    To convert, you multiply SI cholesterol (Total, HDL, LDL) by 39. In your case, for example, a cholesterol of 4.5 mmol/l would convert to 175.5. HDL would be 58.5, and LDL = 93.6. To convert for triglycerides you need to multiply by 89, which would make your triglyceride level 62.3, which is very good indeed.

    To go the other way, from US units to European units, you would simply divide the US units by 39 (for cholesterol figures) and by 89 for triglyceride numbers.

    Cheers–

    MRE

  19. You convinced me to stop taking a statin (simvastatin) because statins don’t improve all cause death rates. Now I read in a Johns Hopkins white paper on heart attack prevention that in a study of high dose Lipitor in elderly CHD patients, all cause mortality was improved relative to moderate dose Pravachol. (I’m 78.) No comparison was made to a low carb diet, of course. What is a guy to think?

    I would like to see the paper.