(Lipid) Love Is Blind

New guidelines for heart attack treatment are smitten—but their love is unrequited

Back in my day, roughly the 16th century, Cupid was often depicted as a blindfolded angel. Because love is blind, random, and often blinding.

Last week the American Heart Association and the American College of Cardiologists professed their love in a new guideline for doctors on treating heart attacks. Among the “Top Take Home Messages” from the document: Give high-dose statin drugs, and other lipid-lowering agents.

Which, for anyone who knows the evidence, is an act of pure love, raw emotion, and a wishful heart. Ah, but if only statins loved them back.

For starters, the (debunked) theory underlying cholesterol treatment, the Lipid Hypothesis, says cholesterol causes heart disease therefore lowering it should prevent heart disease. So, um, what’s that got to do with treating a heart attack?? Isn’t that like rearranging chairs on a sunken ship? Putting on the seat belt after the crash? Closing the barn . . . you get it.

But never mind how it works, the AHA has proof! Giving high-dose statins early in a heart attack, they say, reduces ‘major cardiac events’ in the weeks that follow.

Ahaaaa. Yaaas, yaaaas. If true this could be important, since heart attacks do indeed lead to a vulnerable period of months during which strokes, repeat heart attacks, and deaths are much more common. And what is the proof for statins, you say? The guideline cites four studies, and based on them classifies statins during a heart attack as ‘1A’—their highest recommendation, from the strongest possible scientific proof.

Before we peruse the trials they cite, let us first acknowledge that the world’s most comprehensive review on this topic, published by the respected Cochrane group, found the drugs have absolutely zero effect on deaths, further heart attacks, or strokes. In fact the Cochrane group showed that none of the 18 trials testing statins for heart attacks found a benefit. Not one. Zero. Zilch. Zip. Nada. Naught. N. . . you get it.

So what’s the AHA talking about?

It turns out in a few older trials there was a tiny (1.5%, seriously)¹ reduction in ‘unstable angina’, a nebulous, cautionary, presumptive diagnosis cardiologists used to make when they saw patients with chest pain but normal blood tests, i.e. no heart attack. Perhaps, the theory went, the pain reflected subtle heart effects that the tests could not detect. But that diagnosis is now extinct because new, super-sensitive blood tests find even a scintilla of heart damage. Therefore the one dubious, judgment-based ‘benefit’ that advocates may have touted is no longer relevant. It’s not a thing.

As for the four studies cherry-picked by the guideline? Cupid’s work. The first is a comparison of high-dose versus low-dose statins—not placebo—and it found the higher doses had no effect on deaths, strokes, or heart attacks. The second tested 16 weeks of statins versus placebo after a heart attack, but again found no benefit other than a small reduction in the now-obsolete ‘unstable angina’. The third study found no benefit with four months of statins—but an increase in serious muscle damage due to the drugs. And the fourth is a meta-analysis of statin-versus-other-statin trials, doubly irrelevant since it includes studies unrelated to acute heart attacks.

The new guideline is deeply in love. Blind as bats, the authors claimed to review the evidence and even made gestures that looked scientific, like citing studies and using terms like ‘major adverse cardiac events’. Scary!

The sad part is that statins don’t seem to love them back. Even for patients experiencing an extremely vulnerable and high-risk period of cardiac risk, for whom the drugs should be life saving, the drugs failed to validate the Lipid Hypothesis and failed to reduce heart attacks or deaths. The statins broke their vows.

Although, based on the guideline committee’s disclosures, more than a third of the committee has financial ties to drug makers that sell lipid-lowering drugs.

So maybe love isn’t totally blind after all.

1. See page 63 of the Cochrane report, analysis 2.7, where the control rate of unstable angina diagnoses at 4 months was 6.3% (275/4369), with a RR of 0.76. That’s a 24% reduction from 6.3%, to 4.8%.