This is a transcript excerpt of Jeffrey Bland, PhD, speaking at a Town Hall (Seattle, June 2, 2008). He reviews published evaluations of statins, arguing that randomized-trial evidence shows low absolute benefit in primary prevention (citing a number-needed-to-treat >50 over five years and trial data showing a reduction from ~2.3 to ~1.7 events per 100 people, a 0.6 per-100 absolute difference or ~37% relative reduction). He contrasts this with clear benefit in secondary prevention, notes equivocal trial evidence for women, and explains how relative-risk framing can mislead. Bland recommends offering patients a 12-week nonpharmacologic trial and shared decision-making, then situates this clinical stance within a broader theme of individual empowerment and healthcare reform.
Questions this video answers
January 2007 (Lancet).
More than 50 people must be treated to prevent one event over five years (NNT > 50).
Without statins: ~2.3 per 100; with statins: ~1.7 per 100 (absolute difference 0.6 per 100).
Approximately a 37% relative reduction (0.6/2.3 ≈ 0.26 — Bland states 37% in the talk).
A 12-week trial of nonpharmacologic measures as a first-line option.
Chapters
And when Wright did this evaluation, lo and behold, he published in a very well respected medical magazine, the Lancet Medical magazine in January of 2000, was it? Yes, January of 2007. A year ago. A little over a year ago. This particular are lipid lowering guidelines evidence based? I'll summarize. You can read that while I'm summarizing. But what he found was that lo and behold, when you really looked at statins effect in primary prevention, the data that is published from which decisions are made today suggests strongly that you have to treat more than 50 people with statins to get one favorable outcome over five years. That's what's called an NTT in pharmacology, the number to treat NTT. And a pharmacologist will tell you that any drug that has an NPT greater than 50 is a crack shooter. It's not a very good drug. Now am I saying statins are bad drugs? Please be careful here, I don't want to mislead you. In secondary prevention where the person has already been selected for having a cardiac trial by having a heart attack, there is absolutely no question that statins are good in secondary prevention. That data is assuredly low NTT and for sure it works. And what we have made an assumption in medicine is if it's good for secondary prevention, it must be good for primary prevention. But the difference is that you get a self selection of people who have a heart attack that may be more sensitive to statins than if you just treat the garden variety of high cholesterols. So when he actually analyzed the data in the women's studies of heart disease, knowing that heart attack and post menopausal women is the major risk factor to women's health after menopause, it was found that there was not a single bit of evidence to support statins to be used in women at all. Based upon randomized clinical control trial data that's now published, does that mean that no woman should ever be on statins? No, that's not what it means. It just means the data is equivocal. It's not so strong as you might see. Now you say, well I don't understand it because I see advertisements on television that must be authentic that say if I'm on statins it'll lower my incidence of heart disease by 2/3 or by 40%. Where does that number come from? They can't have you be lying to us, can they? And by the way, those same numbers are in the back of medical journals. So they're saying it to doctors, too. So what's with this? And what's with this is as follows. The incidence of heart attack in an average group of people, if you take 100 people who have elevated cholesterols, about 2.3 per hundred, that group of people on statins, their incidence is 1.7 per hundred. The difference between 1.7 and 2.3 is 0.6 people per hundred, which is a 37% reduction in the relative incidence of heart disease. It's absolute versus relative risk difference. Do you follow what I just said? I'm playing with numbers here. Now, how do you think they're going to broadcast their numbers? Are they going to say it reduces the incidence from 2.3 per hundred down to 1.7 per 100? Or are they going to say a 37% reduction of heart disease incidence? It's not lying. It's just using the numbers in a way to be very persuasive. So the point I'm trying to get you to understand is once you get to that question in your mind, then the next question is, okay, well, what would you recommend then, Jeff? Because elevated cholesterol is a surrogate marker for heart disease. So what are you going to do? Just allow that person to wander off into the unknown? And the answer is no. I'm going to suggest that we have a conversation with that patient about their function, because cholesterol is a surrogate marker that relates somehow to their cardiovascular function. And we're going to give them the opportunity to select, just as these four people did something different. If they don't want to select that, that will be their choice. We always have pharmacotherapy. So the first line of therapy then, is to give them the option for doing something over 12 weeks to see how good they can get the results without relegating themselves to a lifelong commitment to pharmacotherapy. Now, why am I saying that this is advantageous as we talk about healthcare reform in 2008? Because you have been given the power to the people. You have turned back the authority as the person who regulates their own life. Who owns that person's life? Does the pharmacology own that person's life? Does the doctor own that person's life? Maybe that person owns their own life, but they can't know that until they've been introduced to themselves. Now, this metaphor for healthcare is a metaphor for our society. Now, I'm waxing philosophically. I apologize. I'm on my soapbox. But the cultural schism we have today is one of disenfranchisement of the individual from themselves. It's one of lack of affirmation that the individual is worth something. It's this Yatermon belief that we're all homogenized within this great sector of unknowingness and that someone else has to tell us the answer because we're not intelligent, wiser or well educated enough to really understand how to manage our own lives, how to manage our destiny, how to create even fulfillment, goodness or a sense of value. Most of us, we find when we do studies on the the Beck's Depression Inventory, go around with this great hole in our own self attribution. Feel like I'm not even worthy of making a decision for myself. I have low attribution. So how do you change this mentality? Because I believe health is a very intimate part of this whole equation, isn't it? Health is something, it's our personal thing. And if we can't get a person to take a sense of their ownership of their health, what Alberto Bandura calls self efficacy, then how can we be responsible stewards of the world? How can we go out and do great things to solve challenges for plants and animals in this biosphere? So to me there's a lesson here. It's not the only road to enlightenment, but it is a path to enlightenment as a culture. To say here is an option if we want to talk about health care reform for 208 is that is meaningful to the individuals. Let's give you options to understand where your dysfunction arises. Because biomedicine is now developed at such a point that we have explanations. When I was in Medical School 40 years ago, we didn't have explanations. We didn't know the origin of any age related chronic disease. We had speculations. Today we have known mechanisms, we've crossed a threshold of knowingness, but we're not allowing patients to be part of that sacred trust with themselves to, to say, you know, we're going to give you some options and you can manage this yourself. It's the most cost efficient way. And when it does, you're going to actually be on a road that's going to be smooth. You can travel at the speed that you want to. In fact, the metaphor I've been using recently is this. I call it the rocky road of life, right? What happens while we're living? We collect a bunch of potholes in our road of life and we want to travel at high speed, sometimes in the passing lane. But when we try to get up to high speed, there's so much vibration in our body's symptoms that we have to slow it way down. So the speed limit goes for us from 60 to 45. And if we just continue on that road, the potholes get deeper and deeper and deeper until they become ruts, until we finally become high centered. And we get high centered in something we can call that's the rut of coronary heart disease. That's the rut of cancer, that's the rut of diabetes, that's the rut of arthritis, whatever it might be. Then we have a hook that comes and pulls us out of that chasm and takes us to a place that does crisis repair. But well, before then, if we start reading, you know, saying that our road is getting rutted, we have opportunities to do road repair and to lay a smooth surface, but we have to ask the question, who's responsible for that road repair? And what I'm really thinking right now is, I think very thoughtfully about this healthcare reform concept superimposed over is universal accent. Down below is personal responsibility. Down below is educating people that they're in charge. Down below are giving authentic options. Down below is to talk about the most magnificent process of self repair which exists within our genes. If we just get the junk off the top of it, people say, well, you know, I expect to have all these symptoms because actually I am older. Yeah, that's true. The one sure thing is death. But as James Freeze talks about in his 1980 article in the New England Journal of Medicine, aging, compression, and natural death, he says, we can compress morbidity into the last few moments of our life, and we can undergo natural death by deciding to move on rather than.
