Black patients less likely to receive statins

Eliot A. Brinton, MD, FAHA, FNLA

We don’t have a lot of data like these, so simply having this additional study is interesting. This is a national registry and their focus was on the disparities in statin treatment between white and black patients, while other races were excluded.

The findings add to our knowledge base in terms of black patients. One of the problems has been that black individuals tend to have more than their share of stroke and heart disease. The question is why and what to do about it? It’s a very important question.

Regarding the results, one thing that I find interesting is the high percentage (60%) of people using the 2013 ACC/AHA guideline as their primary treatment modality. I would not have guessed it to be so high. This is surprising because few have fully embraced those guidelines, largely because we try to treat to goal, but those guidelines don’t offer lipid treatment goals. This study reports less aggressive statin treatment among black patients. They’re showing something that we already knew or thought we knew.

This study also tested on-treatment levels of LDL and other major lipids. Using standard LDL goals of less than 70 mg/dL for secondary prevention and less than 100 mg/dL for primary prevention, the slightly lesser degree of LDL goal attainment among black patients is not surprising, although it’s interesting to have that documented in this particular dataset.

The most striking finding of this study is the lower degree of trust of the medical establishment, in general, among black patients. That is a known issue, and other people have documented that, but interesting to see again. In particular, this paper found that black individuals were less likely than white individuals to believe statins were safe, 36.2% vs. 57.3%, more than a 1.5-fold difference. Further, the percentage is low for both races, just barely over a third vs. just over one-half.

A related finding was trust in clinicians, 82% vs. 94% among black and white patients, respectively. Looking at the percent of individuals who do not trust their clinicians, the difference is more dramatic, 6% vs. 18% in white vs. black patients, respectively. This means that three times more black patients did not trust their clinician, while about one-and-a-half times more did not believe that statins were safe. I believe that these are the most important findings of the whole paper. It suggests that we have an action item, in that we need to improve patient trust in us and in our primary lipid treatment: statins.

Hypertension, MI and stroke are more common among black Americans and therefore, lipid treatment is more important in them, but the lack of trust among those patients make adequate treatment harder to perform. Since only 36% of black patients believe statins are safe, then 64% do not believe that statins are safe. That is a huge deal because statins are the basis for our treatment in the vast majority of patients. Statins are, by all objective data, very well proven to be safe, so there’s a need for better communication addressing cultural differences, and clinicians may not be aware of this need. Many clinicians would be both astonished and discouraged with these results.

Around 64% of the black patients thought that statins were not safe, with the reasons listed being diabetes, muscle aches or pains, liver damage or memory loss. Among secondary prevention patients, only 10% of black patients vs. 6% of white patients thought that statins could cause diabetes. Interestingly, fewer patients in primary prevention thought this, which seems a little counterintuitive. Further, the way the question appears to have been worded — “I think statins can cause diabetes” — is actually true. It’s a fact that statins can cause diabetes, so if you take that question at face value, it’s actually surprising how few people say yes and how many say no.

The data on muscle aches or pains are also interesting. Many primary prevention patients think that statins can cause muscle aches or pains, 36% of the white patients, 21% of the black patients. That difference is large, statistically significant and in the opposite direction of what one would predict. That is, more concern on the part of the white patients and less among black patients. The same trend was seen in secondary prevention and is also statistically significant, 42% of the white patients and 34% of the black patients feel that statins can cause muscle aches or pains. Interestingly again, the way that’s worded, yes, even the most hardened clinical trialist would agree that they can. They would say that at worst, only 1% of the patients will have muscle symptoms, but they would have to say, “Yes, they can.”

For the question of whether statins can cause liver damage, in primary prevention, the white patients were again way over the black patients, 28% vs. 15%. Secondary prevention has a much narrower difference, 29% vs. 25%, but in contrast, this is a question to which most objective observers would answer, “No.” The FDA has backed away from even asking us to test the liver unless there was a preexisting reason.

Memory loss is something that is not proven in clinical trials, but certainly is a common complaint in the clinic. The black patients say this a little bit more common than the white patients, 15% vs. 12%, in secondary prevention, but it’s even, 10% and 10%, in primary prevention. You would think that this would give you the answer as to why any patient would say that they don’t trust statins, but for every one of these, with a partial exception of memory loss, the white patients are way more likely to believe that there are problems than do the black patients.

That does not give us any reason why statins aren’t trusted. I just don’t get that. The vast majority of the patients — two-thirds to three-quarters — say that statin medications are effective in reducing the risk for heart disease and stroke. So most patients agree that they’re effective and not that many of them say that they are unsafe in one particular way or another.

Oddly, continuing in table 2, although a much higher percentage of primary prevention patients who are white say that statins are safe (55%) vs. those who are black (32%), in every specific issue of safety, it is the white patients who are more concerned. These findings seem to be self-contradictory. Also, it is disappointing that this study offers no explanation of why so many of these patients do not trust statins.

A further conclusion is that most participants were not receiving appropriately aggressive statin therapy. That’s something that we’ve known before, but it is nice to have race-specific data.

There is another issue in this regard that is not addressed in this paper. It is that about half of patients who are prescribed a statin will stop taking it within a year or so.

Unfortunately, this particular study does not address the clinician’s side of the story. What are the issues here with statin treatment from the clinician’s perspective?

Perhaps the most glaring need for future research is to explore the reasons for lack of patient confidence in the safety of statin therapy and how those reasons may differ by race.