Author + information
- Prediman K. Shah, MD⁎ ()
- ↵⁎Cedars Sinai Heart Institute, Los Angeles, Suite 5513, 8700 Beverly Boulevard, Los Angeles, California 90048
I appreciate the comments by Dr. Cooper regarding my Viewpoint paper (1). I fully concur with Dr. Cooper that 30% to 50% relative cardiovascular risk reduction with statins is a highly clinically worthwhile benefit, but I beg to differ that unconditional treatment of everyone without known atherothrombotic cardiovascular disease and hyperlipidemia with a statin is appropriate. It is an established fact that atherothrombotic cardiovascular disease does not develop in a significant proportion of subjects with hyperlipidemia, and, conversely, a significant proportion of subjects with atherothrombotic cardiovascular disease do not have hyperlipidemia; in fact, the real definition of what constitutes hyperlipidemia is itself unclear. If the goal of using a statin is to reduce atherothrombotic cardiovascular events, then it is unrealistic to expect those patients without significant atherosclerosis to benefit from statin therapy even if they have hyperlipidemia; in such subjects, one can only expect side effects and extra costs associated with statin use. Fortunately, we now have the ability to identify subclinical atherosclerosis in 2 major vascular beds noninvasively so that those patients without atherosclerosis can be observed and reassessed while adopting a healthy lifestyle without resorting to statin therapy. Because hypertension has adverse effects beyond simply an association with atherosclerosis, such as increased risk of stroke, especially hemorrhagic stroke, renal failure, congestive heart failure, and aortic aneurysm formation, one cannot equate hyperlipidemia management with hypertension management. Similarly, smoking-associated health risk includes lung disease, cancer, and thrombotic cardiovascular events even with minimal atherosclerosis; smoking cessation is advisable for every smoker regardless of other risk factors. In this day and age, where we are headed toward the concept of “personalized medicine” (matching treatment to underlying risk and disease phenotype rather than a “one size fits all” strategy, which has been the prevailing paradigm), the approach outlined in my Viewpoint paper is a step in that direction.
- American College of Cardiology Foundation