~ Dr. Irving Loh
All of us who prescribe cardiovascular drugs realize that our patients get their medical information from many sources other than us. Once prescribed a medication, many of our patients may read the packet insert, but more likely go to Dr. Google or his cousin, WebMD, and other websites of variable credibility and focus that may have 800 numbers at the bottom, offering our patients “alternatives” to our pharmacologic, read “tainted scientific” data for their statin information. Or commonly, they get information from well-meaning friends, family, or their other healthcare providers who have their own networks of non-evidence based information gathering, many of which promote homeopathic or fad diet based interventions.
We accept all of this as part of our taking care of autonomous, sapient human beings. But there may be another facet in all of this for us to consider. This post was stimulated by two additional pokes. One was my nurse sister-in-law telling me that one of her nurse colleagues was considering stopping her statin because a surgeon told her that half of all patients taking statins got Alzheimer’s. And the second was a timely article in the European Heart Journal from 2 December 2015 (1) that examined the clinical implications of patient exposure to negative information. If interested, please look at the original article linked below.
This interesting report from a Danish national cohort study examined data from 675,000 people who were prescribed statins between 1995 (<1% population on statins) and 2010 (11% population on statins). These investigators focused on what patients did after hearing negative news stories, most often about adverse effects. If patients did not refill their statin at 6 months, they were felt to have prematurely discontinued their therapy. 6% of patients on statins discontinued them in 1995, 18% discontinued in 2010. Discontinuation was understandably more prevalent in individuals who were free of clinical cardiovascular disease or who perceived themselves as being in good health.
The national Danish Civil Registration System allows Denmark to follow its citizens from birth until death, and many events in between. Social network paranoia aside, this methodology allows for fairly precise tracking of its citizens for purposes of research. Knowledge of medication use was linked with the national Danish Registry of Medicinal Products Statistics. Statin related news stories were culled from the Danish Infomedia database using targeted search terms and rated as positive, negative or neutral by the investigators. Individuals exposed to negative media were 9% more likely to not refill their statin prescriptions. Their methodology is detailed in the article.
Patients who actually stopped taking their statins were at a 26% increased risk of MI and an 18% increased subsequent risk of a cardiovascular death. Obviously, there are large numbers of other variables with possible impact on these results, and many of these are discussed in the article, but the gist of the article is that negative information may prompt discontinuation, and that discontinuation may have negative clinical implications. The quantitative assessment of the impact is limited to Denmark and the population therein, so your mileage may vary…
We almost always warn our patients of the dangers of not being compliant with prescribed medications, especially those cardiovascular drugs with Class IA indications. But now there is some actual study of the problem that negative information, whether gathered by news stories or casual conversation by influential friends, family or authority figures, may prompt patients to stop their medications and perhaps suffer the consequences. As I say to essentially all my patients, it is their right and likely prudent responsibility to research recommendations made by their doctors, and I welcome their bringing their findings to their next visit or, if urgent, by telephone or secure email. I tell them just don’t do anything until we have had the opportunity to discuss their decision options. I tell them that Google gives them lists of things, but not relevant priorities that may (or may not) apply to their circumstances.
1. European Heart Journal doi:10.1093/eurheartj/ehv641, but accessiblebit.ly/21vWVY6 (PDF) European Heart Journal, online December 2, 2015
Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.