Stopping Statins: Pt1 - Is it Safe After an Ischemic Stroke?

Aug 26, 2023

Stopping Statins: Pt1 - Is it Safe After an Ischemic Stroke?

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Content

1.22 -> so today we're gonna talk about stopping

4.14 -> statins I have a friend he's about 60

11.07 -> now his father died of a heart attack

13.71 -> when he was 51 my friend had a plaque

17.52 -> and had some problem it had slowed it

21.449 -> down

21.9 -> he actually reversed it and decreased

29.22 -> the size of that plaque and hardened it

32.61 -> so he felt like he was in good shape and

35.28 -> he was ready to stop it he told me he

37.35 -> did and in less than a year guess what

39.739 -> less than a year off the statin his

42.03 -> plaque had softened again and started

44.73 -> growing so we're gonna talk for a few

47.01 -> minutes about stopping statins actually

49.14 -> there was a study that just came out a

51.539 -> couple of months ago in the Journal of

53.64 -> the American Heart Association talking

56.19 -> about people that have stopped Stanton's

58.559 -> post plaque so we're gonna do a brief

62.37 -> series on stopping statins because

67.439 -> there's a lot of maybe conflicting

71.67 -> information in the literature maybe not

73.53 -> if you understand the mechanisms behind

76.38 -> statins but first a quick introduction

78.659 -> I'm Ford Brewer with preb Med heart

80.88 -> attack and stroke prevention we hope you

82.979 -> get a couple of healthy decades in your

86.759 -> life that you wouldn't have had now what

91.049 -> are the reasons for stopping statins

92.909 -> well there are a lot of them and I've

94.74 -> got a few of them listed here oh one of

97.229 -> them is the side effects

98.72 -> obviously fatigue muscle soreness

102.439 -> malaise and that's a medical term for

104.909 -> feeling bad increasing blood glucose

109.649 -> statins can move you down that diabetic

112.53 -> Highway if you're already insulin

114.09 -> resistant and etc there's just a bunch

116.49 -> of other reasons to think about that and

119.969 -> to want to get rid of them I need to

122.219 -> switch to another statin that's another

125.64 -> reason for example maybe you've been

128.97 -> watching these videos and realize that

131.67 -> you're on the wrong statin

133.48 -> maybe you're on something like lipitor

135.34 -> and your insulin resistant and it's not

137.62 -> giving you any anti-inflammatory impact

140.129 -> other reasons cost fear now you just

144.989 -> actually I talked to most of my patients

150.04 -> are baby boomers and the baby boomer

151.9 -> generation just does not like

153.73 -> medications it's not so much a fear

156.069 -> thing it's just an emotional thing about

157.92 -> we want to be whole and healthy and

161.86 -> natural and anything like a medications

163.959 -> a bad thing so how about another reason

168.31 -> you know believe Rory Collins and the

171.04 -> cholesterol treatment traumas I'll go

174.88 -> over that slide in just a minute or are

180.37 -> another reason you've seen too many

181.75 -> youtubes on the dangers of statins so

185.98 -> yes there's a lot of reasons to stop

187.66 -> statins and we're going to go into a

189.13 -> study that just talked about that with

192.91 -> tens of thousands of patients that stop

196.75 -> their statin post-stroke you remember I

199.18 -> mentioned Rory Collins in the

200.7 -> cholesterol treatment trial lists

203.049 -> there's been a debate going on for at

205.72 -> least six years between the British

208.15 -> Medical Journal and Lancet those are the

211.09 -> two major medical journals medical

216.37 -> science journals for England

218.04 -> Rory Collins is in The Lancet Group it's

222.04 -> been a debate about whether Lant

223.81 -> British Medical Journal has been

225.22 -> publishing things that say statins are

226.84 -> dangerous for you and Rory Collins and

229.6 -> his group are saying yeah they're

231.25 -> dangerous but they're not as bad as

233.25 -> going statin free real quick basically

238.63 -> what he's saying they did a

240.06 -> meta-analysis and he's saying look yes

242.739 -> myopathy can happen in a lot of a

247.09 -> relatively good number of people they're

251.049 -> saying take ten thousand people either

252.94 -> low risk or high risk and I can't

255.76 -> remember if they followed them for five

256.989 -> years or ten years I don't think that's

259.87 -> significant given the numbers that were

261.25 -> talking about but I believe it was five

262.51 -> years and they're saying look you're

264.909 -> gonna see myopathy now this is not just

267.16 -> tenderness or or fatigue this is serious

270.67 -> myopathy which can kill you you're also

273.88 -> going to see increasing insulin

275.83 -> resistance they listed it as new onset

279.79 -> diabetes soon maybe an academic

282.64 -> discussion but there most researchers

285.7 -> would say it doesn't start diabetes when

288.79 -> you don't have it anyway you get a lot

291.25 -> of that moving you down the diabetic

293.59 -> highway you know also get hemorrhagic

296.26 -> stroke or at least that's what they

298.27 -> thought then back a year ago I think

302.62 -> that most of us are beginning to get

304.51 -> comfortable that they really don't so

309.06 -> worst case scenario a hundred ten

311.86 -> hundred and fifteen bad outcomes from

318.51 -> statins in 10,000 people well way the

323.95 -> other side that same ten thousand people

326.53 -> if it was a low-risk group would suffer

328.47 -> 500 heart attacks or strokes fatal by

334.42 -> the way

336 -> cardiovascular death if there were a

338.29 -> high-risk group it would be a thousand

339.76 -> so that's what Rory Collins and his

341.56 -> group are saying and if you cruise

344.32 -> through the YouTube and the internet a

346.57 -> bit you'll see a lot of that debate

348.67 -> still going on but let's talk about this

350.86 -> study that we just saw or that I

352.84 -> mentioned in the American Journal of the

354.91 -> American Heart Association back in

358.45 -> August of oh seven they basically said

361.24 -> look oh it cut off but they're saying

369.7 -> look it's dangerous to to stop your

373.78 -> statins after a stroke I'm just gonna

377.95 -> mention one other study to show that

379.87 -> this is not maybe not as simple as it

383.77 -> seems this was a study done in oh four I

389.74 -> think yeah oh four where they stopped

393.49 -> statins and look at the headline here

395.8 -> stopping statins in the short term is

397.81 -> okay for stable patients

400.82 -> I'll talk about this study a little bit

402.86 -> later but let's go through the recent

406.04 -> study the one published in the Journal

408.47 -> of the American Heart Association August

411.86 -> 2nd of 2017 util utilization of statins

417.85 -> beyond the initial period after stroke

420.5 -> and one year risk of recurrent stroke so

427.33 -> just to get to the punchline and then

429.71 -> dig a little bit deeper into the details

433.84 -> so the results were that they saw

437.8 -> significant increase in stroke recurrent

441.44 -> stroke in patients that stopped their

443.87 -> statins among the 45150 one ischemic

451.19 -> stroke patients meeting the criteria

454.09 -> during the day 92 day 180 period 7% were

458.99 -> on reduced therapy 18.5 were not on any

462.14 -> therapy compared with maintained statin

467.81 -> intense therapy discontinuation of

470.93 -> statins was associated with an increased

475.31 -> hazard of recurrent stroke the

478.01 -> probability meeting the 95% probability

484.03 -> criteria in other words it's less than

487.19 -> 5% probability that this would happen

489.89 -> just out of random chance and actually

492.08 -> we'll go over the actual numbers and

494.96 -> you'll see that the probability was less

496.58 -> than one hundredth of one percent so

500.93 -> their conclusion was look

502.42 -> discontinuation of statin therapy

504.23 -> between three and six months after an

508.55 -> index stroke is going to increase your

511.51 -> probability of having another stroke so

518.14 -> let's let's get a little bit deeper into

522.11 -> the details here this is one of the this

526.91 -> is some of the numbers one of the tables

528.62 -> out of this study

533.14 -> basically what they're showing is the

536.86 -> dip is recurrent stroke and ischemic

544.51 -> stroke now one of the problems with this

549.1 -> study is they didn't clearly define

551.05 -> what's the difference between a

552.31 -> recurrent stroke and an ischemic and a

554.02 -> secondary ischemic stroke but basically

556.24 -> what they showed is you're more likely

558.94 -> to have a stroke here's the numbers let

561.91 -> me see if we can read them at fourteen

564.25 -> [Music]

565.56 -> hundred and seventy four strokes among

568.12 -> the thirty-three thousand six hundred

570.13 -> and twenty-three people who were on who

575.05 -> maintained the stroke the statin therapy

577.26 -> for those that discontinued the statins

580.57 -> that was eight thousand three hundred

582.25 -> fifty-three again a lot fewer 33,000

585.52 -> continued at eight thousand stopped

587.17 -> among the 33,000 that continued at 1500

591.52 -> strokes

592.09 -> among or 4.4 percent among the a

596.08 -> thousand that stopped there were 517

602.5 -> strokes or 6.2 percent again the

605.08 -> probability of that difference is less

609 -> than one hundredth of one percent so

614.16 -> short story is I'm not recommending any

618.19 -> my post stroke patients to stop their

621.16 -> statin there's two problems with this

624.88 -> study though and I may have mentioned in

629.41 -> some of my previous videos I used to do

633.22 -> a lot of epidemiology at Hopkins and so

635.59 -> got very deep into looking at studies

638.88 -> this study is there has some of the same

642.91 -> problems that a lot of other scientific

646.93 -> studies have it's the exclusion criteria

649.75 -> issue first of all this this was in a

653.74 -> Taiwanese registry for strokes it was a

658.09 -> retrospective study meaning they took

659.92 -> information from strokes that had

663.97 -> already occurred and tabulated it

667.12 -> now let's look at the exclusion criteria

669.61 -> the first one is 32,000 were excluded

674.279 -> doing two due to having a recurrent

677.41 -> stroke within a hundred and eighty days

679.089 -> after discharge well I sort of thought

682.36 -> that was part of the study now I'm

686.639 -> thinking that maybe what they're saying

689.68 -> is look stroke you often get one stroke

694.509 -> after another in rapid succession and in

698.079 -> fact it's true a quarter of strokes

700.48 -> happen in people that have already had

702.43 -> one so they were saying let's be

705.639 -> conservative and rule that group out

707.499 -> that's probably reasonable but they

710.439 -> didn't discuss it and again that's where

712.839 -> you get into problems with these studies

715.499 -> they may have perfectly good reasons for

719.17 -> exclusion criteria but unless they

721.839 -> describe them

722.829 -> it's impossible to tell and here's where

725.74 -> you start to see that come out to light

727.779 -> is where the rest of the scientific

729.759 -> medical community starts debating the

734.05 -> quality of that study and the quality of

736.3 -> the logic they'll often start bringing

738.37 -> out what were the exclusion criteria

740.439 -> other exclusion criteria excluded to

744.699 -> follow up less than 180 days that makes

746.889 -> sense excluded due to receipt receiving

749.49 -> hemodialysis well hemodialysis is a

754.959 -> major destabilizer so it's totally clear

759.279 -> why why they would do that 66,000

762.759 -> excluded due to not having antiplatelet

765.819 -> or anticoagulant within 180 days again

768.819 -> reasonable because if you didn't have

772.8 -> antiplatelet treatment that's much more

775.689 -> likely to be the reason for having a

778.36 -> recurrent stroke than statins 120,000

784.629 -> excluded due to not having Stan or a

788.05 -> low-dose statin within 90 days after the

790.569 -> discharge again we have to give the

795.029 -> authors the credit that they knew what

798.249 -> they were doing in they had good logic

800.589 -> behind it I'm not totally hearing it

804.009 -> though

804.989 -> bottom line like I said before their

809.86 -> problems with every study this study's

812.499 -> really good research it has its own

815.23 -> problems but I'm not planning on

818.499 -> recommending any of my post-stroke

821.47 -> patients to stop their statin here's

824.499 -> some questions though why did this why

826.779 -> did this happen why do we see two

828.79 -> studies one which says it's okay to stop

831.369 -> your statin and another one which says

832.779 -> it's not well let's go back and think

835.059 -> about it I think the these two studies

836.829 -> and the results coming from them are

838.239 -> totally reasonable and compatible and

841.179 -> expected the study showing safety was

845.829 -> with stable patients the study showing

849.249 -> hazard was with patients that had had a

852.009 -> recent stroke so this all gets to this

854.379 -> concept my interpretation is plaque

858.249 -> instability is systemic I did a video

862.299 -> recently about that one vulnerable

865.929 -> plaque the theory of the vulnerable

867.879 -> plaque and in fact there have been

869.86 -> companies and startups which were all

872.619 -> based on the assumption that you could

874.36 -> find that one plaque that's creating

877.299 -> danger for the patient that theory is

882.069 -> those companies didn't make it and that

885.429 -> or they morphed into something else and

887.319 -> that theory I think is rapidly dying and

893.439 -> here's why

898.86 -> plaque instability is systemic

901.98 -> therefore if there's no such thing as a

904.72 -> single vulnerable plaque where there's

906.939 -> one unstable plaque there's a whole

909.579 -> arterial tree full of unstable plaques

912.72 -> likewise if your plaques are stable and

917.559 -> healthy relatively speaking they're

921.009 -> going to remain that way so in a study

923.379 -> of people that are stable and healthy

925.209 -> yes it's okay to stop your statins for a

927.61 -> short time period

928.49 -> anyway it certainly appears to be but if

932.089 -> you're unstable already and you've got

934.07 -> evidence of a hot plaque in there you've

936.14 -> got more hot flecks that are waiting to

938.839 -> do damage again thank you for your

942.5 -> attention

Source: https://www.youtube.com/watch?v=SO1X725DZBo