The American Heart Association’s Scientific Sessions have rolled into Dallas this week and the city is awash with two conversations: whether the latest cholesterol guidelines will result in the gross over-prescription of statins to the healthy masses, and the assassination of JFK which happened here 50 years ago this week.
And while these two disparate conversations have very little in common on the surface, they both have a similar core message—individuals really matter.
Within hours of JFK’s assassination, Lyndon B Johnson was sworn in as president. And in time he worked on and passed various legislation, begun by Kennedy, such as the Civil Rights Act of 1964. The office of president moved on and the work of government continued, missing hardly a beat.
But, in spite of his short time in office, Kennedy is repeatedly voted one of the, if not the, greatest president in American history. His speeches are seen as iconic and his legacy era-defining. His face, ubiquitous here in Dallas at the moment, is instantly recognisable and Dealey Plaza, where the assassination took place, is probably as full of cardiologists this week as the Dallas Convention Centre. In the great scheme of things he was the person to fill the job between the 34th and 36th presidents. But as an individual his impact and death was huge. It really mattered who he was as an individual. He was not just president number 35.
Similarly this week, the kerfuffle over cholesterol guidelines has been a strong reminder that patients are more than homogenous cohorts. Indeed, even as individuals, they are more than N=1.
The new cholesterol guidelines have come under criticism for dramatically increasing the potential number of people taking statins. David Goff, the dean of the University of Colorado School of Public Health and the co-chairman of the guidelines’ risk assessment working group, responded at the meeting by saying that one in three people will die of cardiovascular disease and almost twice that number will have a major cardiovascular disease event. Guidelines which encourage the use of statins in roughly a third of adults aged 40-75 would seem to fit with those broad statistics.
However, Neil Stone, who chaired the cholesterol guideline writing committee described things slightly differently: “In my risk discussions, some people don’t get statins when the numbers say they should, but in others, the numbers don’t quite get there but they do.”
He used the examples of a patient whose numbers did not quite reach the trigger score for prescription of statins, but with a striking family history of heart disease, and a patient who came in on crutches who did hit the risk figure. The first was prescribed statins, the second was not.
Research, by necessity, deals with population statistics, but doctors can deal with the patient in front of them. Evidence based medicine demands that physicians have the best research at their finger tips, but it does not demand that they treat each patient as a cohort in a study.
In whatever way the situation develops over the latest cholesterol guidelines, doctors would do well to remember that guidelines are there to be applied not slavishly enacted. And as JFK showed, individuals and their stories still matter as much as the big picture.
Edward Davies is US news and features editor, BMJ.