The results of a major trial showing that taking a statin reduces heart attacks and strokes in "apparently healthy people" have been described as "astonishing", but they aren't astonishing. What may be astonishing and may bankrupt the NHS is the way the results of the trial might be used.
The trial published in the New England Journal of Medicine shows that giving rosuvastatin to patients with "normal" cholesterol cut their chance of a heart attack, stroke, hospital admission for chest pain, or death from cardiovascular disease by 44%. Another and better way to describe the results is that after almost two years of treatment 1.8% (157 of 8901 subjects) in the placebo group had "cardiac events" compared with 0.9% (83 of the 8901 subjects) in the rosuvastatin group. This means that 120 people have to be treated for almost two years to prevent one event. It is very likely, however, that if treatment were to continue for longer – life even – then the results would be much more dramatic.
The results are not astonishing because nobody living in developed countries has a "normal" level of cholesterol. Compared with Pacific islanders untouched by industrialisation (if any such people still exist) we all have high cholesterols, and we know that your chance of having a heart attack or stroke is continuously related to your cholesterol. In other words, as your cholesterol gets higher so does your chance of having heart attack – and this applies even at low levels of cholesterol. There is no point below which we are safe.
Exactly the same goes for blood pressure, blood sugar, and probably exercise. Medicine has fallen into the trap of thinking that you are either "normal" or "diseased" in that you have hypertension, diabetes, or hyperlipidaemia (raised blood lipids). If you are "diseased" you need treatment, and if you're "normal" you don't. Thus I was taught at medical school to "diagnose" high blood pressure and treat it with a range of drugs, changing the treatment until the patient reached a "normal" blood pressure. But high blood pressure is not a disease. It doesn't have symptoms. Rather it's a risk factor for developing a heart attack or stroke.
After I left medical school I learnt about the "prevention paradox," which says that most people who have heart attacks and strokes don't have very high blood pressure or cholesterol. Certainly people with high blood pressure and high cholesterol are at much higher risk of having a heart attack or stroke, but there are many more people at low risk, which is why overall they account for most people with heart attacks or stroke. So most people taken into hospital with a heart attack or stroke or who drop dead from one of the other don't have very high blood pressure or cholesterol. They were "normal" until struck down.
It's recognition of all this plus understanding that you need to treat all risk factors the that has led to the idea of the "polypill", a pill that contains a statin, drugs to lower blood pressure, and possibly aspirin and folic acid. It has been calculated that if everybody stated taking this polypill at age 55 without any testing of blood pressure or cholesterol then heart attacks and stroke would be reduced by 80%.
This idea caused both excitement and outrage when it first appeared in 2003 and made the front page of the Guardian. I loved the idea because it upset everybody. Drug companies were upset because the pill can be produced very cheaply (possibly as low as a dollar a month) and would cut their substantial profits from patented drugs. Doctors were upset because it says that their traditional model of "diagnose and treat" doesn't work. And public health people were upset because it suggests that people could continue to smoke, drink, eat poorly, and fail to exercise and simply take a pill.
Partly because of opposition from all these vested interests, the polypill isn't yet on the market – but there are many different versions (almost all manufactured in India) on their way to market. And if you can be bothered you can take five separate pills each day then they will have the same benefit. I take them.
The danger of this new trial from the New England Journal of Medicine, which was funded by Astra Zeneca, the manufacturers of rosuvastatin, is that the NHS will be pressurised to make that particular statin available to all. But it's not off patent and will be expensive. Plus everybody will have to go the doctor, have a slew of tests, and be followed up. A much more effective and cheaper strategy will be to get everybody who wants to at 55 to start taking a polypill. And the reason you start at 55 is because age alone is the best predictor of your chances of having a heart attack or stroke. Measuring weight, blood pressure, lipids, and blood sugar doesn't add much useful information, and you don't have to bother with those pesky doctors.
