The Senior Center for Health & Security

Saving America's Seniors with Statins:
Addressing a health care crisis could save lives and billions of dollars

Health care reform is front and center on the national agenda. The continuing goal is broader access to better care in a way that will save health care dollars. In our aging society, perhaps no other therapeutic practice can save more lives and more health care dollars than fighting heart disease through the appropriate use of cholesterol lowering medications called statins. The correct statin in the correct dose prescribed for seniors who can safely benefit from these medications can improve health care and save billions of dollars in acute care costs.

The Crisis

Heart disease is the number one killer of men and women in America. This health care crisis must be addressed now, before the Baby Boom Generation doubles the number of 'older' Americans to roughly 80 million. According to the Centers for Disease Control and Prevention (CDC), heart disease kills about 652,091 people in the U.S. each year, accounting for 27% of all deaths in America.

Heart disease is a term that includes a variety of heart conditions including acute rheumatic fever, chronic rheumatic heart disease, hypertensive heart disease, coronary heart disease, pulmonary heart disease, congestive heart failure, and any other heart condition or disease. The most common heart disease in the United States is coronary heart disease, which can lead to heart attack.

An Equal Opportunity Killer

According to CDC statistics, 322,841 men died from heart disease in 2005, making it the leading cause of death among men in the United States. It's estimated that between 70% and 89% of sudden cardiac events occur in men and the average age of a first heart attack for a man is 66 years of age. Almost half of men who have a heart attack before age 65 die within 8 years.

Although heart disease is sometimes thought of as a "man's disease," women account for more than half – 51% - of heart disease deaths in the U.S. Heart disease is the leading cause of death among women age 65 years and older but it also poses significant risks for younger women. Heart disease is the third leading cause of death among women aged 25–44 years and the second leading cause of death among women between 45 and 64 years of age.

The Human and Economic Costs

The loss of life to heart disease and stroke is huge. According to CDC, heart disease and stroke are among the most widespread and costly health problems facing our nation today. Heart disease and stroke are the first and third leading causes of death, respectively, for both men and women in the United States. Together they account for more than one-third (35.3%) of all U.S. deaths and these deaths are not limited to older Americans. More than 151,000 deaths attributed to cardiovascular disease in 2005 were among those younger than age 65.

Heart disease and stroke are also among the leading causes of disability in the U.S. workforce, with nearly one million people disabled from strokes alone. If all major types of cardiovascular disease were eliminated, U.S. life expectancy would increase by nearly seven years. However, the burden of cardiovascular disease cannot be measured by death and disability statistics alone.

The CDC estimates that more than one in three American adults – as many as 80 million – currently have some cardiovascular disease. These patients make 72 million doctor visits each year for treatment and require more than 7 million hospital?izations annually. The price tag for stroke and heart disease in the U.S. is estimated at $475 billion for 2009, a figure which includes health care costs and the cost of lost industrial productivity resulting from disability and death. Staggering as these costs are, they are expected to increase as the nation's population ages.

Costs for Minorities

The impact of heart disease falls disproportionately on certain racial and ethnic groups, placing people in these groups in a higher risk category. Age-adjusted death rates for heart disease among African Americans are nearly one-third higher – 32% – than among whites. Heart disease among Alaska natives and American Indians is almost double the rate among the general population, and the first-stroke risk for African Americans is almost twice as high as it is for whites.

The online edition of the peer reviewed journal Neurology published a study in 2006 estimating the cost of stroke alone to exceed $2.2 trillion over the next 50 years, and those costs will fall disproportionately on Hispanics and African Americans. "The economic burden of stroke in African Americans and Hispanics will be enormous over the next several decades," said Dr. Devin Brown of the Stroke Program at the University of Michigan Medical School in Ann Arbor, the lead author of the study. Per capita costs noted in the study amounted to $25,782 for African Americans, $17,201 for Hispanics, and $15,597 for Non-Hispanic Whites. In an aging society, the individual and collective impact of strokes to these groups will be devastating.

Prevention

While the crisis is real and growing, heart disease and stroke are also among the most preventable disease challenges we face. For that prevention to occur on a broad scale, critical cardiovascular disease risk factors like high blood pressure (hypertension) and high blood cholesterol must be addressed by every at-risk American. The results of such an effort could be rewarding, both in terms of better health and lower costs. This is especially true for the ever-growing legions of older Americans.

High Blood Cholesterol

According to the CDC, decreasing total cholesterol levels by 10% could yield an estimated 30% reduction in coronary heart disease.

As the National Heart, Blood and Lung Institute explains, a person's level of blood cholesterol, a fatty substance that can collect in arteries, has a lot to do with their chances of getting heart disease. High blood cholesterol is one of the major risk factors for heart disease. Simply put, the higher your blood cholesterol level, the greater your risk for developing heart disease or having a heart attack.

When there is too much cholesterol in your blood it can build up and cause "hardening of the arteries" resulting in arteries becoming narrowed and restricting blood flow to the heart. Blood carries oxygen to the heart, and if blood and oxygen reaching the heart decreases too much, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack.

But since high blood cholesterol has no obvious symptoms, many people are unaware that their cholesterol level is too high. This underscores the importance of learning your cholesterol numbers through a simple blood test.

While the risk is higher among older patients and other groups, lowering cholesterol is important for everyone – younger, middle aged, and older men and women. The CDC noted in 2007 that about 105 million U.S. adults had cholesterol levels of 200 mg/dL (milligrams per deciliter) or higher, which exceeds the Healthy People 2010 objective of less than 200 mg/dL established by the Office of Disease Prevention and Health Promotion.

Exercise and diet, determined in consultation with your doctor, are two lifestyle actions that can play an important part in lowering cholesterol. But sometimes, these changes are not enough for people to reach their individual cholesterol goal and many health professionals recommend medication to improve the chances of lowering cholesterol to appropriate levels.

Statins -- Wonder Drugs of Heart Health

While a healthy lifestyle is important, lifestyle modifications may not be enough for some patients, and a doctor may prescribe cholesterol lowering medications called statins. These reduce the liver's cholesterol production and some varieties of statins have lowered cholesterol levels by as much as 60 percent.

In clinical trial after clinical trial, statins continue to exhibit consistent and beneficial results. One of the most recent trials, in November 2008, had truly dramatic findings. According to a WebMD report, healthy men and women who took a particular statin had half as many heart attacks, strokes, and deaths from cardiovascular causes as the group taking a placebo. These patients also saw their LDL cholesterol level reduced by an average of 50 percent. The trial of some 18,000 patients was scheduled to run four years but was ended after less than two years because of the overwhelming success shown in the data.

In a different, unrelated trial of another type of statin, the November, 2008, results provided new evidence that improvements in kidney function in patients treated with the statin strongly correlated with a reduced risk of major cardiovascular disease. This is the first time an association between improvements in kidney function and a reduction in cardiovascular events has been shown.

A third study in late 2007, using a third statin, found that men who took statins for five years had fewer deaths and heart attacks ten years later, even though most had stopped taking the cholesterol-lowering medication. The trial findings suggest that early reductions in LDL cholesterol can have large benefits later in life, in this case a full decade after the five-year treatment period stopped. This is truly a lasting benefit.

These findings are important to women as well. Another 2007 study tracking 27,000 women over 11 years found that controlling cholesterol may be even more important for women than previously thought. The study, published in the journal Neurology, found that healthy women with no history of heart disease or stroke have a significantly higher risk of experiencing a stroke if they have high cholesterol.

The study, conducted by researchers at Brigham and Women's Hospital in Boston, focused on women who were healthcare professionals who were at least 45 years old with no history of cardiovascular disease, cancer, or other major illness. The results of the study found a strong correlation between total cholesterol levels and the later incidence of stroke. The findings show otherwise healthy women with high cholesterol at the beginning of the study were more than twice as likely to suffer a stroke compared to healthy women with lower cholesterol levels.

The American Heart Association noted another 2008 study of particular interest to older Americans. The AHA reported that elderly patients with congestive heart failure who took one of four commonly prescribed statin drugs for lowering cholesterol had a reduced risk of dying after leaving the hospital, no matter which statin they were on. The risk of dying appeared to decrease the longer the patients took the statin. On average, the doses of the drugs were low, and increasing the dose seemed to have no effect. The researchers believe that this increased survival may be an effect of the statins independent of their ability to lower cholesterol.

Cost Savings of Statins

The cost savings that can be achieved through statin use is significant. A January 2001 study published by the American Academy of Family Physicians, found that among middle-aged patients with coronary heart disease, the estimated cost per year of life saved as a result of statin therapy ranges between $4,500 and $14,000. This compares with a cost of $40,000 per year of life saved for emodialysis and $70,000 per year of life saved for coronary bypass surgery for one-vessel.

British researchers came to similar, broad conclusions. A report in the May 12, 2005 issue of the British medical journal The Lancet noted that research determined that "the cost of avoiding future medical problems justifies the wider use of statins." Among patients who participated in this research, it was noted that hospitalization costs for those taking statins were reduced 22%.

How many more could benefit from statin therapy? The number is in the millions. An analysis of government data released in November 2008 showed that at least 80% of men older than 50 and women older than 60 should be taking a cholesterol-lowering drug – roughly 44.7 million Americans.

Statin treatment can dramatically reduced the loss of life due to heart disease while also reducing costly and painful medical procedures needed to restore patients to health according to Paul Ridker of Brigham and Women's Hospital in Boston. Ridker and his research team calculated that treating 5 million to 6 million people for five years would "translate very conservatively into 250,000 fewer angioplasties, surgeries, heart attacks, strokes and cardiovascular deaths in the United States," he said. The overall savings would be huge.

Statins for All -- But One Size Won't Fit All

There are six different statins in the statin drug class, including rosuvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin. While they are in the same class, they are clearly not identical. Each is unique, just like the millions of patients they serve daily. Different patients have different risk factors and require different medications.

Important patient attributes including gender, race, family history, age, and other risk factors should be the decision drivers for prescribing health care providers. High risk patients have an urgent need for the most effective treatment. They shouldn't be forced by cost considerations to use a less effective medication. Doctors must be free to consider every patient as an individual, just as they need the freedom to decide which statin in which dosage is best for each individual patient.

Personalized Medicine and Statins

The November 2006 report, "The Case for Personalized Medicine," explains why personalized medicine is necessary for select optimal therapy.

"Physicians have long recognized that patients can respond very differently to the same medication. For example, a statin drug used to lower cholesterol levels may work for only 30 to 70 percent of patients (Spear et al. 2001). Studies have linked differences in drug responses to differences in genes that code for the production of drug-metabolizing enzymes, drug transporters, or drug targets (Mangravite et al. 2006; Rieder et al. 2005; Terra et al. 2005)."

The personalized approach is critical. While statins can have side effects (and some may be dangerous), the appropriate statin in the appropriate dose will usually work well for the patient. According to the American Heart Association website:

"As a class, statins are very safe medications. They have been widely used for almost 20 years and several studies clearly show that statins reduce heart disease, stroke and total mortality," said senior author Richard H. Karas, M.D., Ph.D., director of the Preventive Cardiology Center and the Women's Heart Center at Tufts-New England Medical Center in Boston. Karas urged doctors to individualize treatment.

Important as personalization is, a greater risk may lie in switching statins or substituting a cheaper medication for one proven to work well for the patient. This should never be allowed to happen without the express agreement of the physician and the patient. Costs for brand name medications and insurance formularies are constantly changing. Without good communication between patients and their healthcare providers, patients may not know they already have affordable access to the most effective medications.

Helping patients to meet or exceed their cholesterol goals must be the first priority for everyone connected to the treatment process. Cost must never be put ahead of quality health care. If it is, there will be resulting consequences. Health care providers, insurance companies, and government agencies that treat all statins alike may well be making a costly and dangerous miscalculation.

The best treatment outcomes begin with a solid doctor/patient relationship. That's where the discussion begins. Proper diet and exercise, along with the right statin in the right dose if necessary, pave the road to improved heart health and lower health care costs.

Conclusions

America is an aging nation. We stand at the edge of a retirement population numbering up to 80 million people, and one of the biggest threats to every one of those older Americans is heart disease and stroke.

Widespread, well-monitored use of statins for everyone at any risk of suffering from these debilitating diseases would translate into superior medical outcomes and lower costs. Patients, physicians, and all health care providers must ensure the broadest, most appropriate use of statins, not only for the good of most if not all aging Americans, but for the economic well-being of the nation as a whole.

Physicians must work tirelessly to make sure the right statin is prescribed in the right dosage to the right patient. And finally, patient adherence to their individual treatment regimen is critical. Millions of lives and billions of health care dollars will be saved as a result of these efforts.