Heart disease is the number one killer in the United States, hands down, and cholesterol-lowering drugs, known as statins, have long proven successful in helping reduce the risk for heart attacks and strokes.
But a new study from Boston researchers finds that among patients at the highest risk of developing cardiovascular disease, more than one in five refused to take statin medication.
And those most likely to say “no thank you” were women. The study published Tuesday in JAMA Network Open found that women were about 20 percent more likely than men to refuse statin therapy when it was first suggested by their physician, and 50 percent more likely than men to never accept the recommendation.
“It may be that some women are less accepting of the fact they have cardiovascular disease, that [they think] this is a man’s disease,” said Dr. Alexander Turchin, senior author of the study and director of quality in diabetes at Brigham and Women’s Hospital Division of Endocrinology, Diabetes, and Hypertension.
Heart disease is often underestimated in women, specialists say, because of the misperception that they are protected against heart problems. Their estrogen is heart protective, and women have a reduced risk for heart disease compared to similarly aged men. But women’s risk for cardiovascular problems rises substantially after menopause.
The study delved into the medical records of more than 24,000 patients within the Mass General Brigham health system from 2000 through 2018. The study, however, did not explore what prompted patients to decline statins.
The researchers focused on high-risk patients, with an average age of 59, who either had coronary artery or vascular disease, diabetes, very high cholesterol, or had suffered a stroke. All were recommended statin medications by their physicians to reduce their risk of heart attack and stroke and reduce cholesterol levels.
Dr. Rebekah Gardner, an attending physician at Rhode Island Hospital’s Center for Primary Care, said she finds that women are more likely to be reluctant about statins. She said it may be that women have read or heard about studies involving potential side effects from taking the drugs, such as muscle aches, and in those studies, women more frequently reported problems.
Gardner said women may also be more likely to share those thoughts and experiences with each other and also be more open to trying alternatives to statins.
“Women may be more motivated to try and make lifestyle changes before trying a medication, like changing up their diet or more exercise,” Gardner added. “I see that all the time as well.”
Who would be the best candidates for trying diet and exercise first?
“For many patients, a trial of diet and exercise would be a completely reasonable approach and may even be preferred because it would provide benefits beyond mitigating cardiovascular risk,” Gardner said in an e-mail. “Patients in this group might be those with a moderately elevated cholesterol level but without heart disease, diabetes, hypertension, tobacco use, etc.”
But she noted that for patients in the new study, lifestyle changes would be recommended in addition to the statin, not as a substitute.
“Statins would be the strong recommendation here because those patients are a very high-risk group, and, for them, prior research has shown that taking a statin can reduce heart attacks and strokes beyond lifestyle changes alone,” Gardner said.
One finding that surprised Turchin, the study’s senior author, is that patients most likely to decline statins had English as their primary language. He isn’t sure what to make of that, but wonders if these patients are more comfortable searching the Internet for information about statins and are then dissuaded from taking them by reams of often misleading articles about the medications.
When Turchin searched sites such as Amazon and Facebook, he said, mostly negative information popped up.
“The first thing that comes back is ‘a statin-free life,’ ‘the dark side of statins,’ ‘the truth about statin risks,’ and ‘alternatives to cholesterol-lowering drugs,’ ” he said.
Turchin said pharmaceutical companies had no input into the current statin study. He has, separately, received research grants from two companies that manufacture statin medications, but said the funding is for unrelated studies on obesity and potassium.
Other physicians who prescribe statins said the study’s findings about large numbers of patients declining the medications ring true in their experiences.
Dr. Russell Phillips, a primary care general internist at Beth Israel Deaconess Medical Center, said that often the decision by his patients to start taking a statin is not made in a single office visit, but stretches out over months and several discussions.
And that process, he said, can be challenging for time-pressured primary care physicians who must explain the need for lifelong treatment with a statin for something that is not causing the patient any apparent symptoms and seems like an abstract risk sometime in the future.
“I would love to have resources that I could direct patients to that would lay out the risks and benefits for them,” Phillips said. “There are decision aids created to help patients think about benefits for mammograms and colonoscopies, but not many for this decision.”
The Boston researchers found patients who were most likely to accept statins when they were recommended were those typically at the very highest risk for heart attacks and strokes: they either had diabetes, extremely high levels of LDL or “bad” cholesterol, a history of smoking, or had already suffered an adverse cardiac event.
That meshes with Dr. James Udelson’s experience.
“Once they have had something bad happen, it’s easier to get people to [take the medication], stop smoking, after they had a heart attack or stroke. It’s never easy but it’s easier,” said Udelson, chief of cardiology at Tufts Medical Center.
The study found that about two-thirds of the patients who were being recommended statin therapy eventually tried it. And, among those who initially declined but then relented, it took three times as long for them to reduce their LDL cholesterol levels to less than 100 milligrams per deciliter (a standard measure), compared to people who took the drugs right away.
Gardner, the Rhode Island Hospital physician, said the study provides physicians some valuable insights.
“Going into the encounter knowing that folks may decline and may later accept, that was a finding that I thought was really encouraging, that they might accept it later and so to not give up,” she said.
“Maybe I need to slow down and ask how they see the benefits and risk, and maybe we can find common ground.”