Every day, around eight million Britons dutifully swallow statin tablets prescribed by their GPs to reduce their risk of heart disease. The drugs are designed to lower cholesterol, thus slashing the chances of a fatal heart attack, and they are among the most widely used medicines in the world.
Yet mounting evidence suggests a significant number of people need not be taking them in the first place. More worrying, others with ‘hidden’ cardiovascular disease – who would benefit from drug treatment – are thought to be missing out because they tick too few of the ‘high-risk’ boxes GPs use to work out the danger to patients’ health.
Given that statins can have side effects ranging from headache and nausea to muscle cramps, many patients would jump at the chance to find out if they really need to be taking them. Research suggests just 50 per cent of adults prescribed the drug stay on them for more than a year.
Heart test one: ‘With my history, the results were such a relief’
Fiano Bates , a property management consultant from Islington, North London, knows firsthand the benefits of a calcium scan. She had one of the worst family histories of cardiovascular disease her heart specialist had ever seen.
Her grandmother, a former professional ballerina, died from heart disease aged 54. Her mother suffered three heart attacks and had triple bypass surgery before the age of 60, and her maternal uncle died of a heart attack at 56.
Fiano Bates , a property management consultant from Islington, North London
Meanwhile, Fiona’s father had lifelong high blood pressure, which led to a stroke in his 70s. Despite leading a healthy lifestyle herself, Fiona, left, had consistently high cholesterol levels and her GP advised her to take statins to reduce her risk of heart disease.
But Fiona, now 63, was reluctant because she was concerned about potential side effects and unsure whether there was evidence that, in her case, they were necessary.
She paid to have a CTCA scan which revealed a calcium score of zero – she had no calcium deposits. Her arteries were entirely clear.
Her consultant, cardiologist Azad Ghuran, advised against taking statins. ‘The scan gave me peace of mind. With my history, it was such a relief,’ says Fiona.
So imagine if there was a rapid, non-invasive and highly accurate test to show – once and for all – who really needs to be on the pills? Well, such a test already exists in the UK.
But while it is readily available at private clinics, it is not widely used on the NHS.
Now, as clinics across the United States roll out the five-minute test for all patients with an intermediate risk of a heart attack, British experts are questioning whether to deploy this powerful weapon on the front line of the war against killer heart disease.
Called calcium scoring, the procedure involves a non-invasive CT scan, which uses X-rays of the heart to look for calcium deposits in the coronary arteries. The deposits can cause them to narrow, and increase the risk of a heart attack. This calcium, unrelated to calcium consumed in our diet, occurs as cholesterol and fat builds up in the arterial walls over time, prompting inflammation. The body’s response to inflammation is to deposit calcium, which stiffens the arteries.
There is also growing excitement about a more sophisticated form of the test, called CT coronary angiography (CTCA), which could prove even more revolutionary, say experts. This scan not only maps calcium and the degree of narrowing in the arteries, but detects fatty cholesterol deposits that can build up inside heart arteries without symptoms, particularly in the young, who may have no calcium in the arterial walls.
Heart test two: ‘I’ll have to take statins for life but I know they work’
Even in his 20s, Kevin Bird knew he was at risk of heart problems.
Several family members, including a grandfather and two maternal uncles, had died of heart disease, and his mother had suffered a heart attack in her 40s.
Despite quitting smoking and eating healthily, Kevin’s cholesterol levels were persistently high. But his GP had always been reluctant to prescribe statins because he was too young.
Kevin Bird, 40, from Stevenage in Hertfordshire
After turning 40 last year, father-of-two Kevin, from Stevenage, Hertfordshire, had a full medical assessment as part of his job as a project manager for Tesco.
It revealed he was a ‘borderline’ case for further investigation on his heart. He chose to be referred to consultant cardiologist Azad Ghuran, who performed calcium scoring with CTCA.
It revealed calcium build-up in his arteries, and Kevin began taking a lowdose statin. Three months on, his cholesterol levels have halved.
Kevin, left, said: ‘There’s an obvious male issue with having this insight, a head-in-the-sand approach. ‘Colleagues and friends all said, “Oh, I’d rather not know.” But given my family history, and knowing what was already starting to happen to me, taking the statins felt like the right thing to do, even though I’ll now have to take them for life.’
Some cardiologists now believe these highly effective tests should be used to screen patients before they get ill to see if they already have harmful calcium deposits lining their arteries. This more targeted tactic could mean statins are directed specifically at those who need them, rather than what some critics say is more of a ‘carpet bombing’ approach.
Dr Paul Jenkins, medical director of the private European Scanning Centre, which offers both calcium scoring and CTCA, said: ‘CTCA is the only technique which can detect what cardiologists call the “widow makers” – the areas inside the coronary arteries comprising cholesterol and lipids which haven’t yet calcified but which can suddenly burst, causing a total blockage, and kill by causing a massive heart attack without any prior warning.’
The tests are only currently available on the NHS to patients with chest pain who are being investigated for heart disease.
Extending their availability to everyone who qualifies for a free heart risk assessment would be hugely expensive. CTCA also requires scanners which can cost up to £2 million each.
Critics also caution that the test involves being exposed to small amounts of radiation. But supporters say it could prove cost-effective in the long run if significant heart disease could be prevented.
Heart test three: ‘Now I know my risk of a heart attack… it’s ZERO’
I’m not what you’d call an obvious candidate for a heart attack, writes Health Editor BARNEY CALMAN.
At 10st, my weight is normal for my height (5ft 8in). I don’t smoke, I don’t drink much and I try to go to the gym but I probably eat way too much cheese.
I’m 40 this year. My father, 73, has suffered severe angina and there’s family history of high blood pressure.
So when I was offered the chance to have a CTCA, which costs about £500 privately, I was confident – but not sure – I’d be given the all-clear.
Health Editor Barney Calman
The test took about five minutes. First, while lying on a bed, an IV needle was inserted into an arm vein. A special contrast dye was injected into a blood vessel and travelled around the bloodstream.
Because X-rays cannot pass through the dye, it helped create a highly detailed image of the heart and arteries.
The scanner creates a 3D image of the heart and surrounding blood vessels, which shows soft plaques and hardened calcium deposits, their position and whether they are causing blockages.
The scan gives a ‘calcium score’, which can be zero if no calcium is detected. Anything between one and 100 is deemed low risk, 101 to 300 is intermediate risk, over 300 is high risk.
My results? ‘Completely clear – zero heart attack risk,’ I was told. ‘Have a glass of wine to celebrate.’ So I did.
Currently, GPs assess a patient’s heart risk during a NHS Health Check by using a scoring system called Qrisk.
It gives a general idea of cardiovascular risk over the next decade based on factors including cholesterol, blood pressure, age, weight and health history. Anyone with a risk of ten per cent or more will be offered statins, according to guidelines.
But Qrisk does not measure the actual condition of a patient’s arteries. As a result, some experts fear that millions may be taking cholesterol-lowering medication when they do not need to.
Data compiled by the European Scanning Centre, based on more than 3,000 cases, suggests that almost 60 per cent of women, and 40 per cent of men under 55 being treated with statins under the current guidelines, have perfectly healthy heart arteries, meaning they probably do not need medication. The astonishing study also found that around a quarter of men and 15 per cent of women may have such significant calcium deposits that the standard dose of statins dished out by GPs would be inadequate to treat it. These patients, say experts, would require further medication or a surgical procedure to lower their heart attack risk.
The study also looked at men and women who were not on statins, and were otherwise healthy with no symptoms of heart disease.
In this group, more than half of men over 55, and almost a third of those aged 40 to 55, had calcium build-ups that put them at risk of heart disease.
Shockingly, around 17 per cent of the older men were in the highest risk category, meaning a sudden heart attack would be likely.
Dr Azad Ghuran, consultant cardiologist in London and Hertfordshire, said: ‘One patient I saw was 35, with low cholesterol and a normal BMI and blood pressure but was having chest and hand pain. His QRISK score was just two per cent. You’d probably say he didn’t yet need a statin. But investigations showed all three of his arteries were severely narrowed.’
In such serious cases, patients can have bypass surgery to improve blood flow around the heart and reduce the risk of a heart attack. Alternatively, they can opt instead – as Dr Ghuran’s patient did – to have less invasive surgery to insert stents to widen the arteries.
Trials are investigating the benefits of CTCA. Later this year, a British Heart Foundation-funded study called SCOT-HEART2 will start to recruit up to 10,000 people aged 50 to 70 with a single risk factor for cardiovascular disease, such as smoking, high blood pressure or raised cholesterol.
The trial will examine whether CTCA improves long-term health outcomes as well as the cost-effectiveness of picking up heart disease earlier.
Professor David Newby, BHF’s Duke of Edinburgh Chair of Cardiology at the University of Edinburgh, who will be leading the study, said: ‘We hope to identify people who are asymptomatic who are actually at risk of heart attacks – and prevent those heart attacks. It could justify giving the scan to people with a singular risk factor.
‘But we need the evidence before recommending it as a standard screening test.’ NHS patients being investigated for heart disease sometimes only receive a calcium score, using a standard CT scan, which reveals whether they have calcium deposits present and may need further treatment. In contrast, CTCA provides a map of the heart and the precise location of any blockages, but can only currently be done in a handful of NHS trusts which have the expensive scanners.
In the US, where Donald Trump had a CTCA scan in 2017, medical guidance to doctors recommends wider use of the calcium scan.
The American Heart Association says all patients over 55 – even if they have no symptoms of heart disease – as well as younger patients over 40 who have an intermediate risk of having a heart attack, should be tested. It follows studies showing half of those aged 45 to 84 offered statins actually had a calcium score of zero, which means the drugs were not clinically necessary.
It will not be a cheap solution. Mr Jenkins says: ‘The scanners also need experienced radiographers to operate them as they’re like Formula 1 cars.’
Others question if the evidence currently supports CTCA’s use for routine screening. One study, SCOT-HEART1, found that it cut the number of deaths from heart attacks by nearly half within five years. But Jonathan Hill, consultant cardiologist at HCA London Bridge Hospital, warned: ‘CTCA will replace calcium scoring for investigating chest pain, but the screening question is controversial in otherwise healthy patients. The radiation risk, although it’s going down, is not quite low enough with most machines.’
Professor Sir Nilesh Samani, medical director of the British Heart Foundation, said that while CTCA was an ‘important tool’, its use over and above calcium scoring alone was ‘somewhat debatable’. He said: ‘We need to find out which groups could benefit, which is what SCOT-HEART2 will do.’
However, Dr Jenkins added: ‘If this could be introduced for every patient over 40, you’d save on statin prescriptions and long term on potential heart problems too.’