“If you think health care is expensive now, wait until you see what it costs when it’s free.”
— P.J. O’Rourke
I’ve written several times about the proven benefits of a family of cholesterol-lowering medicines called statins. Statins include the medications Crestor, Zocor, Lipitor, Mevacor, Pravachol and others. The group has a solid base of evidence showing that they prevent strokes and heart attacks in patients with high cholesterol and in patients who have had a stroke or heart attack.
This week, a study published in the New England Journal of Medicine brought us more good news about statins, and potentially broadened their usefulness. The study has received a lot of attention in the mainstream press. The study randomized over 17,000 patients who:
- were men over 50 or women over 60
- did not have a history of heart disease, stroke or diabetes
- had normal cholesterol (LDL < 130)
- and had an elevated C-reactive protein ( > 2)
C-reactive protein (CRP) is a blood test that is a general marker for inflammation. CRP has long been known to be elevated in people at higher risk for heart attack, but until now, there’s never been anything known to decrease that risk.
The patients were randomized to Crestor 20 mg daily or placebo and were followed for an average of almost two years. The patients on Crestor had fewer heart attacks, fewer strokes and fewer deaths from any cause – a pretty remarkable finding in a group of patients who are not at high risk of cardiovascular illness.
These results strongly support checking a CRP in older men and women and considering statin therapy in those with an elevated CRP regardless of their cholesterol levels. There are some caveats, though. This group of patients had a fairly low risk of adverse events and it took a very large number of patients to show a difference between Crestor and placebo. Extrapolating from the results of the study, it would take treating about 277 patients for two years with Crestor to prevent one heart attack, and 346 patients to prevent one stroke. Using the current price of Crestor, the cost of Crestor needed to prevent one adverse event is over $170,000. The price would be less with a generic statin, but it’s still a big expense and a lot of patients taking a statin who don’t benefit. But we don’t know ahead of time who is the one patient who will have the stroke or heart attack.
So will I recommend checking a CRP to my older patients? Yes. Will I recommend statins to patients with an elevated CRP? Probably, but with the explanation that the benefit may be quite small.
Economists call this the law of diminishing returns. The more resources you spend on a problem (in this case, stroke and heart attack prevention) the less benefit you get from each incremental increase in spending. At some point the possible benefit is so vanishingly small that costs aren’t worth it, but that point is different for every patient. Each one of us has different preferences, different attitudes about risk, and different ways to spend our finite resources. In a free market each patient would balance the risks and benefits herself, but in our current system in which we all indirectly pay for each other’s medicines the decisions will likely be made by insurance companies and by national expert groups.
(I’m grateful to my colleague Dr. Roy Artal and to the several patients who emailed me about this story.)
New England Journal of Medicine article: Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein
New York Times article: Cholesterol-Fighting Drugs Show Wider Benefit
USA Today article: Crestor would save lives at $500,000 each