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Medical Forum / General / Cardiology / November 2007Should a women get a statin
CLINICIAN'S CORNER Drug Treatment of Hyperlipidemia in Women Judith M. E. Walsh, MD, MPH; Michael Pignone, MD, MPH JAMA. 2004;291:2243-2252. Context Several clinical trials have evaluated the effects of lipid- lowering medications on coronary heart disease (CHD). Many of the trials have not included enough women to allow sex-specific analyses or have not reported results in women separately. Objectives To assess and synthesize the evidence regarding drug treatment of hyperlipidemia for the prevention of CHD events in women and to conduct a meta-analysis of the effect of drug treatment on mortality. Data Sources We searched MEDLINE, the Cochrane Database, and the Database of Abstracts of Reviews of Effectiveness for articles published from 1966 through December 2003. We reviewed reference lists of articles and consulted content experts. Study Selection and Data Extraction Studies of outpatients that had a treatment duration of at least 1 year, assessed the impact of lipid lowering on clinical outcomes, and reported results by sex were included. Outcomes evaluated were total mortality, CHD mortality, nonfatal myocardial infarction, revascularization, and total CHD events. Summary estimates of the relative risks (RRs) with therapy were calculated using a random-effects model for patients with and without a previous history of cardiovascular disease. Data Synthesis Thirteen studies were included. Six trials included a total of 11 435 women without cardiovascular disease and assessed the effects of lipid-lowering medications. Lipid lowering did not reduce total mortality (RR, 0.95; 95% confidence interval [CI], 0.62-1.46), CHD mortality (RR, 1.07; 95% CI, 0.47-2.40), nonfatal myocardial infarction (RR, 0.61; 95% CI, 0.22-1.68), revascularization (RR, 0.87; 95% CI, 0.33-2.31), or CHD events (RR, 0.87; 95% CI, 0.69-1.09). However, some analyses were limited by too few CHD events in the available trials. Eight trials included 8272 women with cardiovascular disease and assessed the effects of lipid-lowering medications. Lipid lowering did not reduce total mortality in women with cardiovascular disease (RR, 1.00; 95% CI, 0.77-1.29). However, lipid lowering reduced CHD mortality (RR, 0.74; 95% CI, 0.55-1.00), nonfatal myocardial infarction (RR, 0.71; 95% CI, 0.58-0.87), revascularization (RR, 0.70; 95% CI, 0.55-0.89), and total CHD events (RR, 0.80; CI, 0.71-0.91). Conclusions For women without cardiovascular disease, lipid lowering does not affect total or CHD mortality. Lipid lowering may reduce CHD events, but current evidence is insufficient to determine this conclusively. For women with known cardiovascular disease, treatment of hyperlipidemia is effective in reducing CHD events, CHD mortality, nonfatal myocardial infarction, and revascularization, but it does not affect total mortality. ' Seems to be weak evidence of benefit Thanks Vince bigvince <Vince.Miraglia@gmail.com> wrote in part: >CLINICIAN'S CORNER >Drug Treatment of Hyperlipidemia in Women [quoted text clipped - 53 lines] > >Thanks Vince It only covered studies completed through 2003. Women with heart disease are older than men with heart disease. It is hard to improve mortality in the very elderly because of mortality substitution effects. Note that the mortality confidence interval is 0.77-1.29, hardly conclusive of no mortality benefit. Later studies have also changed this. -- Jim Chinnis Warrenton, Virginia, USA > bigvince <Vince.Miraglia@gmail.com> wrote in part: > [quoted text clipped - 66 lines] > conclusive of no mortality benefit. Later studies have also changed > this. Here is a more recent meta-analysis. Curr Med Res Opin. 2007 Mar;23(3):565-74. Impact of gender on statin efficacy. Dale KM, Coleman CI, Shah SA, Patel AA, Kluger J, White CM. University of Connecticut School of Pharmacy, Storrs, CT, USA. OBJECTIVE: To determine the impact of statin therapy on the combined endpoint of cardiovascular events in women and men separately. RESEARCH DESIGN AND METHODS: A systematic literature search through May 2006 was conducted to identify randomized, controlled statin trials evaluating the gender specific incidence of cardiovascular events. Weighted averages were reported as relative risks (RRs) with 95% confidence intervals (CI) calculated via random-effects model. MAIN OUTCOME MEASURES: The primary outcome measured was a composite endpoint of all cardiovascular events. Secondary outcomes measured included death, myocardial infarction (MI), and stroke. RESULTS: Fifteen trials were included in this meta-analysis. Cardiovascular events were reduced in men (RR 0.76 [95% CI 0.70, 0.81]) and women (RR 0.79 [95% CI 0.69, 0.90]). Reductions in mortality, MI, and stroke predominantly contributed to the reduction in cardiovascular events in men taking statins. Women did not have a reduction in mortality or stroke, suggesting that the reductions in cardiac events may have been predominantly due to reductions in need for revascularization and/or unstable angina. CONCLUSIONS: Statins reduced the risk of cardiovascular events in men and women, but women on statins may not have reductions in mortality and stroke like their male counterparts. PMID: 17355737 http://tinyurl.com/398elz  SignatureJuhana http://ruohikolla.blogspot.com/ "Juhana Harju" <nope@mail.fi> wrote in part: >Here is a more recent meta-analysis. > [quoted text clipped - 24 lines] > >http://tinyurl.com/398elz Unfortunately, they don't give the mortality results for women in the abstract. I don't have access to the full text. It's hard enough to try to evaluate secondary endpoints when a composite endpoint is used in a single study. It's virtually impossible in a meta-analysis of multiple studies using composite endpoints. But this may be well done. It looks interesting, and I wish I had time right now to dig up a copy and read it. My day job has me on a short leash at the moment. -- Jim Chinnis Warrenton, Virginia, USA > > It only covered studies completed through 2003. > [quoted text clipped - 39 lines] > > http://ruohikolla.blogspot.com/- Hide quoted text - Since no statin study has shown mortality benefits in women this 'but women on statins may not have reductions in mortality and stroke' This study also does not appear to be confined to primary prevention. I think Jim made the comment that "Note that the mortality confidence interval is 0.77-1.29, hardly conclusive of no mortality benefit. Later studies have also changed this. " I would like a reference to the later studies he refers to ,this one from 2007 seems very like the one from 2004 . Perhaps Jim has a newer study; perhaps not. Thanks Vince Vince, What do you propose for women who are at high cardiovascular risk? Do you propose that none of these women be prescribed statins, or would you allow any exceptions? Would you advocate not permitting statins to be prescribed to such women even if they want to take one? I'm not on a statin currently, because to the best of my knowledge I am not at high risk of a heart attack currently. If I ever did decide to take a statin, however, I sure as hell wouldn't ask your opinion first. Marilyn > Vince, > > What do you propose for women who are at high cardiovascular risk? Do > you propose that none of these women be prescribed statins, or would > you allow any exceptions? Would you advocate not permitting statins > to be prescribed to such women even if they want to take one? I don't know what Vince proposes, other than corn chips, but I was, for many years, in the top decile of CVD risk based upon my lipids profile, and have since fallen well below average in risk. Dietary modification, even without exercise, did it for me, even as I've battled hypercortisolemia, which raises serum lipids among a host of other life shortening effects. My paternal relatives died of CVD pretty close the age your husband's did. Susan > Dietary modification, even without exercise, did it for me, even as I've > battled hypercortisolemia, which raises serum lipids among a host of > other life shortening effects. My point was that, in the final analysis, what you or I do with our bodies is none of his business. Marilyn > My point was that, in the final analysis, what you or I do with our > bodies is none of his business. But I responded, as a woman here, to your question. You don't really think that we each have to limit ourselves to posting along gender lines, do you? Information is information, and no one can make you choose to follow anything. I will say, as long as he's pushing corn chips as a vehicle for anything, he's bozo filter material, IMO. Susan > x-no-archive: yes > > > My point was that, in the final analysis, what you or I do with our > > bodies is none of his business. > > But I responded, as a woman here, to your question. OK. > You don't really think that we each have to limit ourselves to posting > along gender lines, do you? Information is information, and no one can > make you choose to follow anything. That's true, and I'm not saying men can't discuss women's health issues or vice versa. It's just that his obsessive focus on whether women should be prescribed statins strikes me as a little paternalistic. It reminds me of men who blather on about whether women should be allowed to have abortions. IMO, if men could get pregnant there would be a lot fewer men who oppose abortion. Are you kidding me? Abortion would probably be a sacrament. Marilyn MarilynMann <mannm@comcast.net> wrote in part: >IMO, if men could get >pregnant there would be a lot fewer men who oppose abortion. Absolutely. I'll add that anyone who opposes abortion is free not to have one. At present, based on the studies I've read, I have to say that the choice of a statin seems reasonable to me when risks of cv disease is high enough. That absolute risk may need to be higher for a woman to have the same benefit/risk balance. I don't know. The data aren't very persuasive to me one way or the other. And if absolute risk can be reduced by other means, one may fall below the threshold for choosing a statin. I don't think other means include corn chips with plant sterols, though. -- Jim Chinnis Warrenton, Virginia, USA > At present, based on the studies I've read, I have to say that the choice of > a statin seems reasonable to me when risks of cv disease is high enough. > That absolute risk may need to be higher for a woman to have the same > benefit/risk balance. I don't know. The data aren't very persuasive to me > one way or the other. If statins are any good at all. The statin literature seems to sound just like the feminine HRT drumbeat that just ended once a non profit entity examined the data honestly. You seem, to me anyway, to accept the assumptions/assertions as if they've been independently verified and well proven. After decades of "it's well known that HRT prevents CVD, stroke, dementia..." It's not the only example, but it's the trajectory I truly believe the statin literature is most likely to take. Susan > friend MarilynMann <mannm@comcast.net> wrote in part: > [quoted text clipped - 13 lines] > threshold for choosing a statin. I don't think other means include corn > chips with plant sterols, though. Other means might include going from bigvince to just vince, however :-) Be hungry... be healthy... be hungrier... be blessed: http://TheWellnessFoundation.com/PressRelease Prayerfully in the infinite power and might of the Holy Spirit, Andrew <>< -- Andrew B. Chung, MD/PhD Lawful steward of http://EmoryCardiology.com Bondservant to the KING of kings and LORD of lords. "Andrew B. Chung, MD/PhD" <heartdoc9@emorycardiology.com> wrote in part: ... >> At present, based on the studies I've read, I have to say that the choice of >> a statin seems reasonable to me when risks of cv disease is high enough. [quoted text clipped - 8 lines] >Other means might include going from bigvince to just vince, >however :-) I've wondered about that. -- Jim Chinnis Warrenton, Virginia, USA > Andrew, in the Holy Spirit, boldly wrote: > ... [quoted text clipped - 12 lines] > > I've wondered about that. It is my wish that we can help him. Prayerfully in the infinite power and might of the Holy Spirit, Andrew <>< -- Andrew B. Chung, MD/PhD Lawful steward of http://EmoryCardiology.com Bondservant to the KING of kings and LORD of lords. > That's true, and I'm not saying men can't discuss women's health > issues or vice versa. It's just that his obsessive focus on whether [quoted text clipped - 3 lines] > pregnant there would be a lot fewer men who oppose abortion. Are you > kidding me? Abortion would probably be a sacrament. LOL... agreed as to the latter. But even as an uppity feminist, I don't see the difference between his obesssion with women and statins and, say, my focus on the role of hyperinsulinemia in cancers including prostate, for instance. My view is that information is a good thing, no matter the source, but you have to evaluate all of it on your own once it's presented. Unless it involves tortilla chips. ;-) Susan > But even as an uppity feminist, I don't see the difference between his > obesssion with women and statins and, say, my focus on the role of > hyperinsulinemia in cancers including prostate, for instance. OK, but I don't think it makes any sense to talk about women in general with respect to statins or other cardiovascular interventions. You have to look at individual risk. To take an extreme example, take a woman who's overweight, sedentary, has Type 2 diabetes, smokes, reached menopause at age 45, and has no intention of changing her lifestyle. Should a doctor decline to prescribe a statin just because she's a woman and women in general at age 45 are at low risk of cardiovascular events? I just don't think that makes sense. A lot of women die of heart disease and statins lower the risk of heart disease. Heart disease can cause death but it can also cause unpleasant symptoms like shortness of breath, chest pain, and so forth. Anyway, the horse is already out of the barn. Statins are out there and some women are going to take them, like it or not. Marilyn MarilynMann <mannm@comcast.net> wrote in part: >> But even as an uppity feminist, I don't see the difference between his >> obesssion with women and statins and, say, my focus on the role of [quoted text clipped - 17 lines] > >Marilyn Marilyn, I think the question is a valid one: Do women respond in the same way to statins as men do? It is possible that they don't. This doesn't have to do with level of risk. It has to do with biological differences. So far, I'm not convinced that there is a difference in response. The data supporting such a claim are very weak. But the claim may be correct. -- Jim Chinnis Warrenton, Virginia, USA > Marilyn, I think the question is a valid one: Do women respond in the same > way to statins as men do? It is possible that they don't. This doesn't have > to do with level of risk. It has to do with biological differences. I agree, and I'd like to know the answer. However, even if you could show that women did not respond as well to statins as men, that would not necessarily mean that no woman should take a statin. Marilyn > OK, but I don't think it makes any sense to talk about women in > general with respect to statins or other cardiovascular [quoted text clipped - 8 lines] > unpleasant symptoms like shortness of breath, chest pain, and so > forth. So can statins. > Anyway, the horse is already out of the barn. Statins are out there > and some women are going to take them, like it or not. I do think it makes sense to question how much the mostly male studies apply to women. We know that the diagnostic tests are much less accurate for us, for example. We're very different hormonally, and metabolic syndrome, CVD, are hormone driven conditions. You can't begin to extrapoloate any predictions about statins for women from the Cardiology literature about mostly men. Susan > So can statins. I agree that you have to weigh the risks and benefits. > I do think it makes sense to question how much the mostly male studies > apply to women. We know that the diagnostic tests are much less > accurate for us, for example. We're very different hormonally, and > metabolic syndrome, CVD, are hormone driven conditions. You can't begin > to extrapoloate any predictions about statins for women from the > Cardiology literature about mostly men. Here's a study on this topic for statin treatment post-MI: CMAJ ? January 30, 2007; 176 (3). Sex differences in the effectiveness of statins after myocardial infarction Igor Karp, Shun-Fu Chen and Louise Pilote >From the Divisions of Clinical Epidemiology (Karp, Chen, Pilote) and Internal Medicine (Pilote), McGill University Health Centre, Montr?al, Que. Correspondence to: Dr. Louise Pilote, Division of Internal Medicine, Royal Victoria Hospital, 687 Pine Ave. W, Rm. A4.21, Montr?al QC H3A 1A1; fax 514 934-8293; louise.pilote@mcgill.ca http://ecmaj.com/cgi/content/full/176/3/333 Marilyn > Here's a study on this topic for statin treatment post-MI: > [quoted text clipped - 13 lines] > > http://ecmaj.com/cgi/content/full/176/3/333 There's a story there in the huge percentage who chose to discontinue therapy. Over 40% of each sex. Susan Susan <nevermind@nomail.com> wrote in part: >x-no-archive: yes > [quoted text clipped - 18 lines] >There's a story there in the huge percentage who chose to discontinue >therapy. Over 40% of each sex. I'm afraid the story is often the same as with blood-pressure lowering drugs. People tend to discontinue drugs that have no obvious effects. People will take a trank or an anti-depressant or morphine, but won't keep paying for drugs that don't make them feel better. -- Jim Chinnis Warrenton, Virginia, USA > I'm afraid the story is often the same as with blood-pressure lowering > drugs. People tend to discontinue drugs that have no obvious effects. People > will take a trank or an anti-depressant or morphine, but won't keep paying > for drugs that don't make them feel better. Or for drugs that make them feel worse. Susan > Vince, > [quoted text clipped - 9 lines] > > Marilyn Would guess that Vince believes his health problems are because of the medications he has taken in the past. It would be my hope that he someday realizes that doctors as a general rule do not prescribe medications to healthy people. Be hungry... be healthy... be hungrier... be blessed: http://TheWellnessFoundation.com/PressRelease Prayerfully in the infinite power and might of the Holy Spirit, Andrew <>< -- Andrew B. Chung, MD/PhD Lawful steward of http://EmoryCardiology.com Bondservant to the KING of kings and LORD of lords. > What do you propose for women who are at high cardiovascular risk? A traditional Cretan type of Mediterranean diet, fish oil supplementation, a daily glass of red wine and increased exercise would be a good start. Inclusion of nuts to the daily diet is important as that has been associated with hugely reduced cardiovascular risk in women. A fresh study: Combined Effect of Low-Risk Dietary and Lifestyle Behaviors in Primary Prevention of Myocardial Infarction in Women Agneta Åkesson, PhD, MPH; Christoph Weismayer, PhD; P. K. Newby, ScD, MPH, MS; Alicja Wolk, DMSc Arch Intern Med. 2007;167:2122-2127. _Background_ Limited data are available on the benefit of combining healthy dietary and lifestyle behaviors in the prevention of myocardial infarction (MI) in women. _Methods_ We used factor analysis to identify a low-risk behavior-based dietary pattern in 24 444 postmenopausal women from the population-based prospective Swedish Mammography Cohort who were free of diagnosed cancer, cardiovascular disease, and diabetes mellitus at baseline (September 15, 1997). We also defined 3 low-risk lifestyle factors: nonsmoking, waist-hip ratio less than the 75th percentile (< 0.85), and being physically active (at least 40 minutes of daily walking or bicycling and 1 hour of weekly exercise). _Results_ During 6.2 years (151 434 person-years) of follow-up, we ascertained 308 cases of primary MI. Two major identified dietary patterns, "healthy" and "alcohol," were significantly associated with decreased risk of MI. The low-risk diet (high scores for the healthy dietary pattern) characterized by a high intake of vegetables, fruit, whole grains, fish, and legumes, in combination with moderate alcohol consumption ( 5 g of alcohol per day), along with the 3 low-risk lifestyle behaviors, was associated with 92% decreased risk (95% confidence interval, 72%-98%) compared with findings in women without any low-risk diet and lifestyle factors. This combination of healthy behaviors, present in 5%, may prevent 77% of MIs in the study population. _Conclusion_ Most MIs in women may be preventable by consuming a healthy diet and moderate amounts of alcohol, being physically active, not smoking, and maintaining a healthy weight. http://archinte.ama-assn.org/cgi/content/abstract/167/19/2122 Couple of nut studies: Frequent nut consumption and risk of coronary heart disease in women: prospective cohort study Editorial by Tunstall-Pedoe Frank B Hu, research associate, Meir J Stampfer, professor, JoAnn E Manson, associate professor, Eric B Rimm, associate professor, Graham A Colditz, professor, Bernard A Rosner, professor, Frank E Speizer, professor, Charles H Hennekens, professor, Walter C Willett, professor BMJ 1998;317:1341-1345 Objective: To examine the relation between nut consumption and risk of coronary heart disease in a cohort of women from the Nurses' Health Study. Design: Prospective cohort study. Setting: Nurses' Health Study. Subjects: 86 016 women from 34 to 59 years of age without previously diagnosed coronary heart disease, stroke, or cancer at baseline in 1980. Main outcome measures: Major coronary heart disease including non-fatal myocardial infarction and fatal coronary heart disease. Results: 1255 major coronary disease events (861 cases of non-fatal myocardial infarction and 394 cases of fatal coronary heart disease) occurred during 14 years of follow up. After adjusting for age, smoking, and other known risk factors for coronary heart disease, women who ate more than five units of nuts (one unit equivalent to 1 oz of nuts) a week (frequent consumption) had a significantly lower risk of total coronary heart disease (relative risk 0.65, 95% confidence interval 0.47 to 0.89, P for trend=0.0009) than women who never ate nuts or who ate less than one unit a month (rare consumption). The magnitude of risk reduction was similar for both fatal coronary heart disease (0.61, 0.35 to 1.05, P for trend=0.007) and non-fatal myocardial infarction (0.68, 0.47 to 1.00, P for trend=0.04). Further adjustment for intakes of dietary fats, fibre, vegetables, and fruits did not alter these results. The inverse association persisted in subgroups stratified by levels of smoking, use of alcohol, use of multivitamin and vitamin E supplements, body mass index, exercise, and intake of vegetables or fruits. Conclusions: Frequent nut consumption was associated with a reduced risk of both fatal coronary heart disease and non-fatal myocardial infarction. These data, and those from other epidemiological and clinical studies, support a role for nuts in reducing the risk of coronary heart disease. http://www.bmj.com/cgi/content/full/317/7169/1341 A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist Health Study G. E. Fraser, J. Sabate, W. L. Beeson and T. M. Strahan Center for Health Research, School of Public Health, Loma Linda University, CA 92350. Arch Intern Med. 1992 Jul;152(7):1416-24. BACKGROUND--Although dietary factors are suspected to be important determinants of coronary heart disease (CHD) risk, the direct evidence is relatively sparse. METHODS--The Adventist Health Study is a prospective cohort investigation of 31,208 non-Hispanic white California Seventh-Day Adventists. Extensive dietary information was obtained at baseline, along with the values of traditional coronary risk factors. These were related to risk of definite fatal CHD or definite nonfatal myocardial infarction. RESULTS--Subjects who consumed nuts frequently (more than four times per week) experienced substantially fewer definite fatal CHD events (relative risk, 0.52; 95% confidence interval [CI], 0.36 to 0.76) and definite nonfatal myocardial infarctions (relative risk, 0.49; 95% CI, 0.28 to 0.85), when compared with those who consumed nuts less than once per week. These findings persisted on covariate adjustment and were seen in almost all of 16 different subgroups of the population. Subjects who usually consumed whole wheat bread also experienced lower rates of definite nonfatal myocardial infarction (relative risk, 0.56; 95% CI, 0.35 to 0.89) and definite fatal CHD (relative risk, 0.89; 95% CI, 0.60 to 1.33) when compared with those who usually ate white bread. Men who ate beef at least three times each week had a higher risk of definite fatal CHD (relative risk, 2.31; 95% CI, 1.11 to 4.78), but this effect was not seen in women or for the nonfatal myocardial infarction end point. CONCLUSION--Our data strongly suggest that the frequent consumption of nuts may protect against risk of CHD events. The favorable fatty acid profile of many nuts is one possible explanation for such an effect. http://archinte.ama-assn.org/cgi/content/abstract/152/7/1416 SignatureJuhana http://ruohikolla.blogspot.com/ > > What do you propose for women who are at high cardiovascular risk? > [quoted text clipped - 122 lines] > > http://ruohikolla.blogspot.com/ This is great, and I obviously don't disagree with making lifestyle changes, but there are some women that are unwilling to do that or for whom such changes are insufficient. Marilyn >>> What do you propose for women who are at high cardiovascular risk? >> [quoted text clipped - 40 lines] >> risk of CHD events. The favorable fatty acid profile of many nuts is >> one possible explanation for such an effect. > This is great, and I obviously don't disagree with making lifestyle > changes, but there are some women that are unwilling to do that or for > whom such changes are insufficient. Fish oil capsules alone are probably more efficient for women than statins in reducing cardiovascular and total mortality. The meta-analysis below is not gender specific but as it is known that statins are less effective in women the mortality benefit for fish oils is likely to be even greater. Arch Intern Med. 2005 Apr 11;165(7):725-30. Effect of different antilipidemic agents and diets on mortality: a systematic review. Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC. Basel Institute for Clinical Epidemiology, University Hospital Basel, CH-4031 Basel, Switzerland. BACKGROUND: Guidelines for the prevention and treatment of hyperlipidemia are often based on trials using combined clinical end points. Mortality data are the most reliable data to assess efficacy of interventions. We aimed to assess efficacy and safety of different lipid-lowering interventions based on mortality data. METHODS: We conducted a systematic search of randomized controlled trials published up to June 2003, comparing any lipid-lowering intervention with placebo or usual diet with respect to mortality. Outcome measures were mortality from all, cardiac, and noncardiovascular causes. RESULTS: A total of 97 studies met eligibility criteria, with 137,140 individuals in intervention and 138,976 individuals in control groups. Compared with control groups, risk ratios for overall mortality were 0.87 for statins (95% confidence interval [CI], 0.81-0.94), 1.00 for fibrates (95% CI, 0.91-1.11), 0.84 for resins (95% CI, 0.66-1.08), 0.96 for niacin (95% CI, 0.86-1.08), 0.77 for n-3 fatty acids (95% CI, 0.63-0.94), and 0.97 for diet (95% CI, 0.91-1.04). Compared with control groups, risk ratios for cardiac mortality indicated benefit from statins (0.78; 95% CI, 0.72-0.84), resins (0.70; 95% CI, 0.50-0.99) and n-3 fatty acids (0.68; 95% CI, 0.52-0.90). Risk ratios for noncardiovascular mortality of any intervention indicated no association when compared with control groups, with the exception of fibrates (risk ratio, 1.13; 95% CI, 1.01-1.27). CONCLUSIONS: Statins and n-3 fatty acids are the most favorable lipid-lowering interventions with reduced risks of overall and cardiac mortality. Any potential reduction in cardiac mortality from fibrates is offset by an increased risk of death from noncardiovascular causes. PMID: 15824290 Abstract: http://tinyurl.com/2cucqn Full study: http://archinte.ama-assn.org/cgi/content/full/165/7/725 SignatureJuhana http://ruohikolla.blogspot.com/ First I agree that fish oil is a safe option to statins and probaby has greater benefit in primary prevention than statins because of the lack of risk. Let me respond to the rest of the comments by saying I believe evidence must always guide medical decisions. To often no evidence exist for benefit of treatment. No evidence for example that using atenolol benefits hypertensive patients some evidence that it causes harm.Drug after drug is recommended at least until they are pulled of the market. Statins may well be this type of drug. Low and lowered cholesterol and total mortality* Michael H. Criqui, MD, MPH,,* and Beatrice A. Golomb, MD, PhD, The paper by Strandberg et al. (1) in this issue of the Journal confirms that in relatively young, healthy men from higher socioeconomic strata, a (naturally) low total cholesterol (TC) is associated with increased longevity (2); on average, such men will have lower levels of low-density lipoprotein (LDL) cholesterol. Thus, if you are fortunate to have a low TC as a young man, typically a product of a lot of nature and a little nurture, you can expect to do a little better than your peers not so favored. Can one extrapolate these mortality benefits of naturally low TC in advantaged middle-aged men to middle-aged men of lower socioeconomic status (SES)? Can they be extrapolated to the very low end of the lipid range, or to TC lowered by treatment, ..........or to elderly persons? In each case, the available evidence suggests perhaps not. )....... However, from the limited clinical trial evidence available, lowering TC or LDL cholesterol alone produces no independent benefit for clinical events after the ratio of TC to high-density lipoprotein (HDL) cholesterol has been considered (5,6). In only two clinical trials has the issue of the most relevant lipid measure change been addressed, and change in either the TC/HDL ratio (5) or the apolipoprotein (apo) B/apoA1 ratio (6) accounted for all the benefit from drug therapy........ Increasingly, evidence shows that the level of TC or LDL alone is a poor guide to whether to begin therapy. A recent trial of high-risk patients showed proportional benefit at every level of baseline TC and LDL (9), making use of such criteria for guiding therapy in high-risk patients (as contrasted with assessing risk) of questionable value. ..... .....'What of socioeconomic status? In this study all were "men from the highest social class," a fact that is extenuated by noting, "in the present study we examined within-group differences, which are probably less sensitive to the selective nature of the cohort." However, a meta-analysis by Law and Thompson (15) showed that the relation of low cholesterol to cancer on long-term follow-up was not evident in a meta-analysis of high-SES samples but was evident and significant in meta-analyses of populations of low SES. Indeed, there appeared to be a graded relationship from high-SES populations, to mixed SES, to low SES. This finding cannot be glibly dismissed because there are plausible effect modifiers linked to SES, such as dietary and environmental differences.' ..... ''Increasingly, evidence shows that the level of TC or LDL alone is a poor guide to whether to begin therapy. A recent trial of high-risk patients showed proportional benefit at every level of baseline TC and LDL (9), making use of such criteria for guiding therapy in high-risk patients (as contrasted with assessing risk) of questionable value'... http://content.onlinejacc.org/cgi/content/full/44/5/1009?ijkey=272f72310a596a347 04eb4142828f45c70b122c4&keytype2=tf_ipsecsha Let me highlight 2 points )......." However, from the limited clinical trial evidence available, lowering TC or LDL cholesterol alone produces no independent benefit for clinical events after the ratio of TC to high- density lipoprotein (HDL) cholesterol has been considered (5,6). In only two clinical trials has the issue of the most relevant lipid measure change been addressed, and change in either the TC/HDL ratio (5) or the apolipoprotein (apo) B/apoA1 ratio (6) accounted for all the benefit from drug therapy.....".......''Increasingly, evidence shows that the level of TC or LDL alone is a poor guide to whether to begin therapy" And perhaps more importantly ....'What of socioeconomic status? In this study all were "men from the highest social class," a fact that is extenuated by noting, "in the present study we examined within-group differences, which are probably less sensitive to the selective nature of the cohort." However, a meta-analysis by Law and Thompson (15) showed that the relation of low cholesterol to cancer on long-term follow-up was not evident in a meta-analysis of high-SES samples but was evident and significant in meta-analyses of populations of low SES. Indeed, there appeared to be a graded relationship from high-SES populations, to mixed SES, to low SES. This finding cannot be glibly dismissed because there are plausible effect modifiers linked to SES, such as dietary and environmental differences.' ..... It seems that low LDL levels are related to cancer modulated by SES. In light of the recent finding that statin use was related to an increase in cancer this seems important . " ''Increasingly, evidence shows that the level of TC or LDL alone is a poor guide to whether to begin therapy" " The statement TC or LDL is not a good indicator has been confirmed in recent studies. The link comments furter on the disscusion Thanks Vince > First I agree that fish oil is a safe option to statins and probaby > has greater benefit in primary prevention than statins because of the > lack of risk. Greater benefit because of lack of risk? How does that follow? > Increasingly, evidence shows that the level of TC or LDL alone is a > poor guide to whether to begin therapy. A recent trial of high-risk > patients showed proportional benefit at every level of baseline TC and > LDL (9), making use of such criteria for guiding therapy in high-risk > patients (as contrasted with assessing risk) of questionable > value. ..... This sounds like an argument for using statins more rather than less, since people at high cardiovascular risk appear to benefit regardless of their LDL level. As for TC, I don't think it is generally the basis for treatment decisions. > .....'What of socioeconomic status? In this study all were "men from > the highest social class," a fact that is extenuated by noting, "in [quoted text clipped - 8 lines] > there are plausible effect modifiers linked to SES, such as dietary > and environmental differences.' ..... I'm not sure what point you're trying to make here. Yes, low SES is a risk factor for cardiovascular disease. > Let me highlight 2 points > [quoted text clipped - 8 lines] > shows that the level of TC or LDL alone is a poor guide to whether to > begin therapy" HDL is a negative risk factor under the relevant guidelines. Some people have proposed using the Apo B/Apo A1 ratio, or the TC/HDL ratio. What's your point? > And perhaps more importantly > > ....'What of socioeconomic status? Um, what of it? > It seems that low LDL levels are related to cancer modulated by > SES. I don't know how much evidence supports this. Even if very low LDL caused cancer, a low LDL target might still be appropriate for someone at very high risk of a cardiovascular event. In light of the recent finding that statin use was related to an > increase in cancer this seems important . I don't think there's evidence that statins cause cancer. > " ''Increasingly, evidence shows that the level of TC or LDL alone is > a poor guide to whether to begin therapy" " You need to look at all risk factors, not just LDL. Who is arguing otherwise? Marilyn > This is great, and I obviously don't disagree with making lifestyle > changes, but there are some women that are unwilling to do that or for > whom such changes are insufficient. > > Marilyn Perhaps they do not know what your paragraph opines. The question such changes are insufficient needs a closer look. Bill dealing with a computer upgrade.....YaAAAAAAA SignatureS Jersey USA Zone 5 Shade "The destiny of nations depends on how we feed ourselves." Brillat-Savarin This article is posted under fair use rules in accordance with Title 17 U.S.C. Section 107, and is strictly for the educational and informative purposes. This material is distributed without profit. http://www.ocutech.com/ High tech Vison aid |
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