Negotiated risk reduction

He had called and asked for medication for his cholesterol because he had been told by his wellness program at work that he needed to be on medication for his cholesterol to prevent a heart attack.  He didn’t understand why he needed to take time off work to come in and discuss the risks, benefits, and options before I would prescribe anything. And he was irritated that his wife was making a big deal about it. 

He was a 55 year old machinist accompanied by his wife. He had no personal or family history of heart disease or diabetes, but was on lisinopril with good control of his mild hypertension. He smoked 1 pack of cigarettes daily, exercised 2-3 times a week at the gym, and had no symptoms of heart disease. His total cholesterol was 252, his LDL was 168, his HDL was 42, his fasting sugar was 93, his BP on medication was 122/78 and his BMI was 24.  

We entered his information into a cardiovascular risk calculator. It showed that his risk of a serious adverse cardiovascular event (heart attack or stroke) in the next 10 years was about 18%, compared to about 4% for the ideal healthy 55 year old male, and that his lifetime risk of a heart attack and stroke was about 65%. I told him there were two things they could do to reduce his risk.

I explained that a statin would reduce his risk for heart attack and stroke during the next 10 years by about one third, that there was a very small risk of serious side effects, that about 10% of patients couldn’t tolerate the medicine because of muscle aching, that the medicine slightly increased his risk of developing diabetes, that we would check his liver enzymes after he started the medication or if we changed medications or doses, and that we would monitor his lipids annually. I used a pictogram to show that treating 100 people like him for 10 years would prevent 6 cardiovascular events during those 10 years, but that12 people would have their heart attack or stroke anyway, and that 82 people would take the medication for 10 years to prevent something that wasn’t going to happen.  I asked if they had any questions or concerns.

He was not enthusiastic about taking another medication, but his wife was. He said ‘So if I take the medicine for year, it might make me feel lousy or cause diabetes and there is only a 6% change that it will help me? Doesn’t sound like it is worth it to me.’ But she wanted him to ‘give it a try’ because taking the medication ‘would prevent heart disease’ and she didn’t want him to die of heart attacks like her father and brother. No, I explained, statins don’t prevent heart disease as much as they delay heart disease: with or without statin treatment, 2/3 of 50+ year old male hypertensive smokers will die of cardiovascular disease. 

Then I reminded them that I had offered two ways to reduce his risk. Calling the risk calculator up on my iPad again, I showed him what happened if we changed his information from smoker to non-smoker: his 10 year risk dropped from 18% to 9%. The statin would prevent six cardiovascular events during the next 10 years and giving up tobacco would prevent nine. I asked him if he was interested in help giving up the cigarettes. ‘Oh I can quit, doc. I hate them and I can’t smoke at work. I’ve quit before, no problem, but I can’t stay quit unless my wife quits, too.’

He then turned to her and offered a deal. If she would quit smoking with him,  he would take the statin - but only as long as she stayed a non-smoker. three years later, he is still on the statin and they are both former smokers.



Links to more on this topic::