so today we're gonna talk about stopping statins I have a friend he's about 60
now his father died of a heart attack when he was 51 my friend had a plaque
and had some problem it had slowed it down
he actually reversed it and decreased the size of that plaque and hardened it
so he felt like he was in good shape and he was ready to stop it he told me he
did and in less than a year guess what less than a year off the statin his
plaque had softened again and started growing so we're gonna talk for a few
minutes about stopping statins actually there was a study that just came out a
couple of months ago in the Journal of the American Heart Association talking
about people that have stopped statins post (stroke) so we're gonna do a brief
series on stopping statins because there's a lot of maybe conflicting
information in the literature maybe not if you understand the mechanisms behind
statins but first a quick introduction I'm Ford Brewer with prev Med heart
attack and stroke prevention we help you get a couple of healthy decades in your
life that you wouldn't have had now what are the reasons for stopping statins
well there are a lot of them and I've got a few of them listed here oh one of
them is the side effects obviously fatigue muscle soreness
malaise and that's a medical term for feeling bad increasing blood glucose
statins can move you down that diabetic Highway if you're already insulin
resistant and etc there's just a bunch of other reasons to think about that and
to want to get rid of them I need to switch to another statin that's another
reason for example maybe you've been watching these videos and realize that
you're on the wrong statin maybe you're on something like lipitor
and your insulin resistant and it's not giving you any anti-inflammatory impact
other reasons- cost -fear now you just actually I talked to most of my patients
are baby boomers and the baby boomer generation just does not like
medications it's not so much a fear thing it's just an emotional thing about
we want to be whole and healthy and natural and anything like a medication is
a bad thing so how about another reason you know believe Rory Collins and the
cholesterol treatment trialists I'll go over that slide in just a minute or are
another reason you've seen too many youtubes on the dangers of statins so
yes there's a lot of reasons to stop statins and we're going to go into a
study that just talked about that with tens of thousands of patients that stop
their statin post-stroke you remember I mentioned Rory Collins in the
cholesterol treatment trialists there's been a debate going on for at
least six years between the British Medical Journal and Lancet those are the
two major medical journals medical science journals for England
Rory Collins is in The Lancet Group it's been a debate about whether Lant
British Medical Journal has been publishing things that say statins are
dangerous for you and Rory Collins and his group are saying yeah they're
dangerous but they're not as bad as going statin -free. real quick - basically
what he's saying they did a meta-analysis and he's saying look yes
myopathy can happen in a lot of a relatively good number of people they're
saying take ten thousand people either low risk or high risk and I can't
remember if they followed them for five years or ten years I don't think that's
significant given the numbers that were talking about but I believe it was five
years and they're saying look you're going to see myopathy now this is not just
tenderness or or fatigue this is serious myopathy which can kill you you're also
going to see increasing insulin resistance they listed it as new onset
diabetes soon maybe an academic discussion but there most researchers
would say it doesn't start diabetes when you don't have it anyway you get a lot
of that moving you down the diabetic highway you know also get hemorrhagic
stroke or at least that's what they thought then back a year ago I think
that most of us are beginning to get comfortable that they really don't. so
worst case scenario a hundred ten hundred and fifteen bad outcomes from
statins in 10,000 people well way the other side that same ten thousand people
if it was a low-risk group would suffer 500 heart attacks or strokes fatal by
the way cardiovascular death if there were a
high-risk group it would be a thousand so that's what Rory Collins and his
group are saying and if you cruise through the YouTube and the internet a
bit you'll see a lot of that debate still going on. but let's talk about this
study that we just saw or that I mentioned in the American Journal of the
American Heart Association back in August of 2007 they basically said
look - saying look it's dangerous to to stop your
statins after a stroke I'm just going mention one other study to show that
this is not maybe not as simple as it seems this was a study done in 2004 I
think yeah oh four where they stopped statins and look at the headline here
stopping statins in the short term is okay for stable patients
I'll talk about this study a little bit later but let's go through the recent
study the one published in the Journal of the American Heart Association August
2nd of 2017 util utilization of statins beyond the initial period after stroke
and one year risk of recurrent stroke so just to get to the punchline and then
dig a little bit deeper into the details so the results were that they saw
significant increase in stroke recurrent stroke in patients that stopped their
statins among the 45151 ischemic stroke patients meeting the criteria
during the day 90 to day 180 period 7% were on reduced therapy 18.5 were not on any
therapy compared with maintained statin intense therapy discontinuation of
statins was associated with an increased hazard of recurrent stroke the
probability meeting the 95% probability criteria in other words it's less than
5% probability that this would happen just out of random chance and actually
we'll go over the actual numbers and you'll see that the probability was less
than one hundredth of one percent so their conclusion was, " look
discontinuation of statin therapy between three and six months after an
index stroke is going to increase your probability of having another stroke" so
let's let's get a little bit deeper into the details here this is one of the this
is some of the numbers one of the tables out of this study
basically what they're showing is the dip is recurrent stroke and ischemic
stroke now one of the problems with this study is they didn't clearly define
what's the difference between a recurrent stroke and an ischemic and a
secondary ischemic stroke but basically what they showed is you're more likely
to have a stroke here's the numbers let me see if we can read them at fourteen
hundred and seventy four strokes among the thirty-three thousand six hundred
and twenty-three people who were on who maintained the stroke the statin therapy
for those that discontinued the statins that was eight thousand three hundred
fifty-three again a lot fewer 33,000 continued at eight thousand stopped
among the 33,000 that continued at 1500 strokes
among or 4.4 percent among the a thousand that stopped there were 517
strokes or 6.2 percent again the probability of that difference is less
than one hundredth of one percent. So the short story is I'm not recommending any
my post stroke patients to stop their statin there's two problems with this
study though and I may have mentioned in some of my previous videos I used to do
a lot of epidemiology at Hopkins and so got very deep into looking at studies
this study has some of the same problems that a lot of other scientific
studies have. it's the exclusion criteria. issue first of all this this was in a
Taiwanese registry for strokes it was a retrospective study meaning they took
information from strokes that had already occurred and tabulated it
now let's look at the exclusion criteria the first one is 32,000 were excluded
doing two due to having a recurrent stroke within a hundred and eighty days
after discharge well I sort of thought that was part of the study now I'm
thinking that maybe what they're saying is look stroke you often get one stroke
after another in rapid succession and in fact it's true a quarter of strokes
happen in people that have already had one so they were saying let's be
conservative and rule that group out. that's probably reasonable but they
didn't discuss it and again that's where you get into problems with these studies
they may have perfectly good reasons for exclusion criteria but unless they
describe them it's impossible to tell and here's where
you start to see that come out to light is where the rest of the scientific
medical community starts debating the quality of that study and the quality of
the logic they'll often start bringing out . what were the exclusion criteria
other exclusion criteria excluded to follow up less than 180 days that makes
sense excluded due to receipt receiving hemodialysis well hemodialysis is a
major destabilizer so it's totally clear why why they would do that 66,000
excluded due to not having antiplatelet or anticoagulant within 180 days again
reasonable because if you didn't have antiplatelet treatment that's much more
likely to be the reason for having a recurrent stroke than statins 120,000
excluded due to not having Statin - or a low-dose statin within 90 days after the
discharge again we have to give the authors the credit that they knew what
they were doing - in they had good logic behind it I'm not totally hearing it
though bottom line like I said before their
problems with every study this study's really good research it has its own
problems but I'm not planning on recommending any of my post-stroke
patients stop their statin. here's some questions though. why did this why
did this happen? why do we see two studies - one which says it's okay to stop
your statin and another one which says it's not? well let's go back and think
about it I think the these two studies and the results coming from them are
totally reasonable and compatible and expected the study showing safety was
with stable patients the study showing hazard was with patients that had had a
recent stroke so this all gets to this concept my interpretation is plaque
instability is systemic I did a video recently about that one vulnerable
plaque the theory of the vulnerable plaque and in fact there have been
companies and startups which were all based on the assumption that you could
find that one plaque that's creating danger for the patient that theory is
those companies didn't make it and that or they morphed into something else and
that theory I think is rapidly dying and here's why
plaque instability is systemic therefore if there's no such thing as a
single vulnerable plaque where there's one unstable plaque there's a whole
arterial tree full of unstable plaques likewise if your plaques are stable and
healthy relatively speaking they're going to remain that way so in a study
of people that are stable and healthy yes it's okay to stop your statins for a
short time period anyway it certainly appears to be but if
you're unstable already and you've got evidence of a hot plaque in there you've
got more hot plaques that are waiting to do damage again . thank you for your
attention