Statins have achieved the status of sacred cow in medicine. Most physicians and many patients believe that lowering cholesterol, especially LDL cholesterol, is key to keeping their hearts healthy. Many people believe that drugs like atorvastatin, rosuvastatin and simvastatin will protect them from heart attacks.
Three prominent cardiologists have challenged their colleagues to reexamine the evidence for this pillar of preventive medicine (BMJ Evidence-Based Medicine, Aug. 3, 2020). They performed a systematic review of randomized controlled trials of cholesterol-lowering medicines.
If lowering LDL cholesterol saves lives, these studies should show a clear and consistent relationship between reduced LDL and lower mortality. They do not.
According to the authors, “... mortality and cardiovascular benefit was more frequently reported in RCTs [randomized controlled trials] that did not meet the LDL-C targets than in those that did.” In fact, “In this analysis over three-quarters of the cholesterol-lowering trials reported no mortality benefit and nearly half reported no cardiovascular benefit at all.”
These cardiologists point out that greatly increased statin use over the past 20 years has not resulted in a commensurate reduction in deaths from cardiovascular disease. They suggest something heretical: “In fact, there is some evidence that statin usage may lead to unhealthy behaviours that may actually increase the risk of cardiovascular disease.”
A very large observational study of older veterans published in JAMA (July 7, 2020) has added to the controversy. The investigators tracked 326,981 participants for about seven years. Of that total, 57,178 took a statin-type drug.
Headlines at the time of this publication heralded a 25% lower risk of dying during that time among statin users. That is referred to as “all-cause mortality.” In other words, people who died from traffic accidents, cancer or dementia were counted along with those who died from heart attacks.
When it came to deaths due to heart attacks and strokes specifically, there were 22.6 deaths per 1,000 person-years among those taking statins. For people not on statins, there were 25.7 deaths per thousand person-years. That works out to about three fewer deaths per thousand person-years. Not quite as impressive as reducing the risk by 25%.
Even more puzzling, however, were the statistics on actual heart attacks and strokes. Statins did not reduce the risk of either outcome significantly.
No one doubts that people with diagnosed heart disease should be taking a cholesterol-lowering drug. Those who can’t tolerate statins may need to be on one of the newer PCSK9 inhibitors such as alirocumab (Praluent) or evolocumab (Repatha). But the evidence is far less compelling for people who don’t have diagnosed heart disease.
There are many lifestyle interventions that are important whether or not a person is taking medicine to lower cholesterol. Physical activity, a diet that focuses on plants and minimizes processed foods, along with stress reduction techniques are crucial. You can learn more about these nondrug approaches in our eGuide to Cholesterol Control and Heart. It is available in the Health eGuides section of www.PeoplesPharmacy.com.
Joe Graedon is a pharmacologist. Teresa Graedon holds a doctorate in medical anthropology and is a nutrition expert. Their syndicated radio show can be heard on public radio. In their column, Joe and Teresa Graedon answer letters from readers. Write to them in care of King Features, 628 Virginia Drive, Orlando, FL 32803, or email them via their website: