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Wednesday, 18 July 2018

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    The joint Franco-German non-commercial television network ARTE recently broadcast a television programme entitled "The Big Bluff" about the link between cholesterol, cardiovascular disease, and the use of statins. The programme propounded the theory that there is absolutely no relation between blood cholesterol levels and cardiovascular disease, and asserted that cholesterol has become the "ideal villain" in cardiovascular disease through a series of "scientific approximations". In addition, the programme encouraged physicians and patients to interrupt lipid-lowering treatments and statins, in particular, to avoid any blood lipid assessment and last but not least, suggested that the recommendations issued by professional societies such as the European Society of Cardiology (ESC) are inappropriate and influenced by conflicts of interest.

    This position is astounding and shocking because it is in total opposition to the current state of scientific knowledge regarding the low-density lipoprotein (LDL)—statin—cardiovascular disease triad. It is now established that there is not only a link between LDL cholesterol and cardiovascular disease but in fact that LDL cholesterol is a proven causal factor of atherosclerosis.[1] Secondly, an analysis of almost 25 000 patients found that a reduction of 1 mmol/L in LDL cholesterol was associated with a 20% reduction in major vascular events {rate ratio 0.79 [95% confidence interval (CI) 0.77 − 0.81]}. Statin therapy is associated with a significant benefit in terms of LDL reduction, major vascular events and overall mortality.[2] Indeed, there is a linear relationship between the reduction in LDL cholesterol and the reduction in cardiovascular events, and this relation persists and is safe even at extremely low values of LDL (below currently recommended targets).[3]

    Clearly, in the face of overwhelming scientific evidence, the disinformation campaign launched by ARTE must be unanimously denounced. This is not the first time that negative news stories have circulated about the alleged inefficacy or danger of statins, and the potential consequences on public opinion are immense. Firstly, there are definite negative repercussions for the doctor–patient relationship, which relies on a basis of trust. Clearly, alleging that patients are being prescribed inefficacious medications hand-over-fist by their doctors is not likely to enhance the trust patients accord to the medical profession.

    Secondly, the impact on prevention treatments is major, because it may prompt untold legions of patients to discontinue their treatment without medical advice. This can lead to major clinical consequences, not least of which is death, myocardial infarction and stroke. Nielsen and Nordestgaard investigated the consequences of negative news stories on statin therapy continuation in 674 900 Danish individuals aged 40 or older who were initiated on statin therapy in the period 1995–2010 and who were followed up until the end of 2011.[4] They reported that negative statin-related news stories were associated with a significant increase in statin discontinuation {odds ratio 1.09 [95% confidence interval (CI) 1.06–1.12]}, and among those who discontinued statins, the hazard ratios for myocardial infarction, and death from cardiovascular disease increased [1.26 (95% CI 1.21–1.30) and 1.18 (95% CI 1.14–1.23), respectively].[5]

    Early statin discontinuation vs. continued use and cumulative incidence of myocardial infarction (top panel) and death from cardiovascular disease (bottom panel). Reproduced with permission from Nielsen SF, et al. Eur Heart J 2016;37 (11):908–916. 10.1093/eurheartj/ehv641.

    A similar controversy previously arose in France after a retired professor of medicine published a book denying the benefits of statins on cardiovascular disease. In 2013, an investigation of the impact of this controversy on the use of statins among regular users found that discontinuation rates after this negative media coverage were significantly higher than before it, involving patients at low, but also at very high cardiovascular risk.[6]

    When disinformation on major cardiovascular health issues abounds, the ESC, in particular through its Media Committee, has an important role to play as a source of reliable and balanced information. In addition to the regular publication and update of recommendations for the prevention and management of cardiovascular diseases, the ESC should be a driving force in disseminating scientifically founded information. It must act as a privileged partner for both the public and the press to inform them about matters pertaining to cardiovascular disease.

    Immediately following the television programme, the ESC swiftly published a press release criticizing the content of the broadcast,[7] underlining the need to counteract the potentially harmful effects of statin naysayers. It"s time to set the record straight because the repercussions for the misinformed are potentially catastrophic.

    François Schiele MD PhD FESC ESC; Steen D. Kristensen MD DMSc FESC ESC

    Eur Heart J. 2018;39(5):335-336.





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