Statin Prescribing and Dosing—Failure Has Become an Option

Laszlo Mark; Istvan Reiber; Peter P. Toth

doi:10.1001/jamacardio.2021.0832

Comment & Response

April 28, 2021

Statin Prescribing and Dosing—Failure Has Become an Option

Laszlo Mark, MD, PhD¹; Istvan Reiber, MD, PhD²; Peter P. Toth, MD, PhD³

Author Affiliations Article Information

¹Bekes County Central Hospital Pandy Kalman Branch, Gyula, Hungary
²St George Fejer County Hospital, Szekesfehervar, Hungary
³Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland

JAMA Cardiol. 2021;6(7):854-855. doi:10.1001/jamacardio.2021.0832

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To the Editor We read with great interest the robust study by Adusumalli et al,¹ which compared the effect of passive with active prompts in an electronic health record to improve optimal statin dosing. Even among patients with atherosclerotic cardiovascular disease (ASCVD), there was negligible impact. Inertia for prescribing and titrating statins adversely affects the quality of care. This is remarkable, given that statins reduce risk for myocardial infarction, ischemic stroke, revascularization, and death and that higher doses of statins reduce risk more than lower doses.² The role of low-density lipoprotein cholesterol in atherogenesis is one of the most established cause-and-effect relationships in all of medicine. The optimal dose and potency of statin therapy based on risk is highly defined by guidelines around the world.

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2 Comments for this article

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April 28, 2021

Risk Regression to Zero

H Silverstein, MD | Preventive Medicine Center

Toth writes powerfully: " ... statins reduce risk for myocardial infarction, ischemic stroke, revascularization, and death and that higher doses of statins reduce risk more than lower doses.2 The role of low-density lipoprotein cholesterol in atherogenesis is one of the most established cause-and-effect relationships in all of medicine. The optimal dose and potency of statin therapy based on risk is highly defined by guidelines around the world..." Toth and the criteria definers have confused the issue irreparably. A simple question should have been asked: at what level of nonHDL (not LDL) does ASCVD cease progressing and begin regression? That number is known and should stand as a single goal: a nonHDL of 90 is that "cholesterol answer". For triglycerides it is 100. For BP it is 110-115/60-70. Other biochemical values are similarly known. As 1 physician well said: "First principles. Simplicity..." Had such a clear goal been established, my belief is that statin use and adherence would be far superior.

CONFLICT OF INTEREST: None Reported

April 29, 2021

Humility and Failure.

Chris Ries |

My understanding is that with all the years of its training, medical education is woefully anemic when it comes to nutritional education and it’s effects on the body, no less in cardiology. Too often there is a knee jerk insistence by the medical Community for pharmaceutical intervention as not only the first response, but the presumed only. That is the real “failure.” And with this myopic approach it assumes no other alternatives. Perhaps many non-adherent patients have found another alternative to the ubiquitous prescribing of statins. Perhaps many have decided to change their diets and lifestyle. I am still awaiting a clinical trial comparing head to head the efficacy, side-effects and costs of statins to the Mediterranean Diet. But no sponsors from pharma are taking. Perhaps what we need to adhere to more is a dose of humility.

CONFLICT OF INTEREST: None Reported

Statin Prescribing and Dosing—Failure Has Become an Option

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