I've never had a nuanced discussed with my PCP about medications (or pretty much anything else). The same is true of pretty much everyone I've discussed this big-picture issue with. So while I appreciate the care that it appears that you and some of the commenters here show with patients, that might be the exception.
As for statins in particular, my experience reinforces the general point I made above: I'm a 61-year-old male, a daily runner for 47 of them, weigh what I did in college, no symptoms of chronic disease. My LDL is high enough that it ranks as "elevated." My PCP has twice (via his employer's message portal, not in person) said this means I should be on statins. No discussion of options, no discussion of how the LDL relates to my HDL and triglyceride numbers (which are in the "excellent" range). He knows I run a lot, so he's not going to recommend being more active. But we've not once discussed diet or any other factors. (I weigh 130, so between that and the running he probably thinks I live on oak bark.)
So I just wanted to provide a little insight why some (who have nothing to do with Paleo, etc.) are skeptical. This guy looks at one number and immediately starts talking about medication. Ideally, I would ask, "Can you show me data on people in my demographic with my numbers and activity level and symptoms, and show that statins made a significant difference in MI risk compared to those who didn't take them?" But come on, I get 15 minutes with him once a year. There's no point in even asking the question.
It stinks that you haven’t been able to have a thoughtful conversation with a doctor about this stuff. Every situation is different but it’s disappointing that you haven’t had the chance to discuss yours in detail
I hear you. It's frustrating but as you probably know, it's more the fault of the system that does not allow more time with patients than the fault of your PCP. That's why I read Substacks like this, and listen to podcasts with lipidologists like Dr. Thomas Dayspring. Though I'm not an MD, I've learned enough to know that atherosclerosis can affect even those with a healthy lifestyle, as both age and genes also play a big role. If you want to know whether or not you have it, I would recommend getting a coronary calcium score, and that will tell you whether you need a cholesterol lowering medication, whether it be a statin or ezetimibe if you're a cholesterol hyperabsorber (see my comment above). In most places, a CAC only costs about $100, although you will likely need a referral. Good luck.
Scott, your post peaked my interest because it is common in my practice and other medical practices. To my knowledge, the data that you are referring to specifically doesn't exist. Couple points to help you decide next steps.
1) Age is the #1 risk factor for heart disease (not modifiable). 2) Elevated cholesterol (hyperlipidemia) is a silent disease until it isn't. 3) Your baseline health status is known (appears ideal or better than most) but genetics are not known (family history is only part of the story).
Thank you for this comment and your post you linked to.
I'm definitely not in the running-provides-immunity camp (on this or other medical issues). If I had access to someone with your nuanced knowledge and time, I would eagerly collaborate on an investigation. You don't happen to live in the Portland, Maine area, do you?
Just an anecdote. My Dad was in the position you are in (lean, runner, generally heathy life style, high LDL etc). Went on statins (early days of statins) - had muscle soreness, went back to "an even at that time known to be less effective than statins" drug. Died of a heart attack, massive, blockage to his arteries.
(His Drs and he talked a lot - so the "blame" for this can't be placed on easily).
This is only one case, of course, so you shouldn't take this as medical advice - mileage may vary etc.
PS. I like your writing style! well written vignette! Made me smile in spite of the memory.
Sorry, I don't remember. I can recall that he said he would prefer to be on statins, and if I recall correctly (not certain as this was 35ish years ago), he was a bit conflicted about going back to whatever he had been on before. He had a first heart attack out of the blue, luckily when he got got home from a run. Very luckily, the next door neighbour was some sort of senior nurse.
While he was in hospital that first time, it was very striking that the folks who were in good shape survived much more often than the folks who weren't. (We talked to heart Drs about that, and they said that was the case)...
Anyway, one of my brothers and I who have similar issues (thin, fit, active & high bad cholesterol) are on fairly high doses of statins. We straddle 70 years. Haven't had problems with them..
I think a contributing factor might be that the average layman is not educated in either research design or in statistics, and I wish these topics (at a basic level) were mandatory in high school. Patients only care about what will happen to THEM, while doctors base intervention decisions on population level data because currently, they don't have a sufficiently accurate prediction model as to who will benefit and who will not. For those with high LDL but hesitant to take a statin, getting a CAC score could help. (Seeing the atherosclerosis in my heart was very motivating!).
As for individualizing treatment decisions, there is one thing that CAN be done (but usually isn't). When I first went on a statin, even a high dose was not enough to sufficiently lower my LDL, and my liver enzymes were elevated. Luckily I listened to a podcast with lipidologist Dr. Thomas Dayspring and learned about the Cholesterol Balance Test from Boston Heart, which can be ordered online from Empower Dx and taken at home. The test indicated that I was a cholesterol hyperabsorber, and thus Ezetimibe would work better for me than a statin (and it has, although I still take a low dose statin, since absorption and production can adapt somewhat in a homeostatic manner). Ezetimibe is as cheap as a statin and without the same side effects, and works better than a statin for the roughly 20% of us who are cholesterol hyperabsorbers. Why don't more doctors seem to know this?
Questioning is always good, so kudos to you. Here's my take on that: As for whether the lab produces reliable and valid results, they are CLIA certified and CAP accredited, so the answer is yes, they've been shown to reliably measure what they say they are measuring. As for FDA approval, the Boston Heart Health website states, "This test was developed and its performance characteristics determined by Boston Heart Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration(FDA). The FDA has determined that such clearance is not necessary." Mr. Google verifies that lab developed tests do not require FDA approval. The important point is whether research indicates the results can improve treatment recommendations and outcomes. The pdf that I provided a link to has quite a few research references that do exactly that. In my own experience, my lab results were consistent with my poor response to statins, and my good response to Ezetimibe. I would encourage anybody who is interested to look up the research they provide in their References and decide for themselves, and/or order the test and see if following the test's interpretive recommendations improves your outcomes the way it did with me. Luckily, it is a low risk decision, since both drugs are low risk. And it might just improve your outcomes! Cheers!
I agree there are some OTC lab tests that are unreliable (too many false positives and/or negatives) and that's why it's important to choose a lab that is certified and/or accredited. The Pew article talks about risk, and I agree that's important, which is why I stressed that decisions make based on these test results are low risk. That's why they are not required to be FDA approved (link below). There would be no reason to even take the test if you didn't already know you have high LCL-C. Of course, you could just start with a statin and see how it works like I did and if it doesn't work well, up your dose until your liver labs are high like I did. Personally I'm glad I found out about the test, because if I hadn't I would not even know anything about why statins were not very effective for me, or that there was a more effective alternative, since my PCP never even mentioned Ezetimibe. The apparent lack of awareness among PCP's is what bothers me. Keep in mind, safe and useful lab tests might not even seek FDA approval because of the high cost of getting such approval (same link below), but that doesn't necessarily mean they are harmful, as the FDA can still pull them from the market if harm is demonstrated. As for usefulness, that is where the research is important. But since most PCP's don't know about it, it's up to patients to seek this out and then decide for themselves whether to shell out the $99. I was lucky my PCP then agreed to write an Rx for Ezetimibe, but she wouldn't have even suggested it if I hadn't.
This is an excellent follow-up to Mandrola’s piece. Your point about the differential treatment of statins and antihypertensives is well taken, and I think you’ve correctly identified why statins get such uneven scrutiny in comparison.
I don’t care to get involved in Med Twitter debates, but these conversations often make their way to the exam room. I never use the word “misinformation” because of the modern baggage it carries. I appreciate that patients are trying to navigate the same difficult world that we are.
Honest conversations with patients about uncertainty, probabilities, and personal values aren’t easy—but they are important and meaningful to both me and the patient.
This might be the most reasonable article on statins I’ve ever read, great job. I think the combination of heightened distrust of pharma (not without reason in some cases!), not wanting to feel like you are “broken” for needing to be on a medication for life and the lack of evidence that they do harm gives people license to basically say whatever the heck the want to support whatever argument they want. Facts never beat feelings after all!
In my entire life (70) dealing with doctors, including about 6 cardiologists, I have had my blood pressure taken in a manner consistent with guidelines (arm elevated to heart level) one time, so my confidence in doctors is low. They (and their staffers) can’t do the simplest thing properly. I’ve had to sit in awkward silence as two nurse practitioners working in a large hospital network insisted that hydrochlothiazide is potassium sparing. Perhaps medical credibility would be greater if practitioners were more knowledgeable and competent.
I’ve read the studies evaluated by Dr David Diamond who discusses absolute risk vs relative risk. I then had the discussion with my husband’s cardiologist. This was a year and a half in after an aortic dissection. He finally said well, you could try a low carb diet. In 3 months my husband lost 35 lbs and he had a CAC with a low score. My question then is why didn’t he lead with that? We believe that the risk of adverse effects from the statins are greater than the benefits. We cut seed oils and sugar from our diet. I realize everyone is different and has to choose what is right for themselves.
SO very grateful for this well written, carefully nuanced article that addresses, beautifully, the entire controversy. Thank you for taking the time to write an article that addresses both pro and con sides of the debate. As a health professional I’ve long wanted a balanced piece to give my non-medical friends who believe the blanket idea that all statins are bad for anyone. Merci!
Lies, damn lies and statistics. Or something like that from Mark Twain. In today's world it seems studies can be manipulated in almost any way he who does the study desires. As someone who has been reading you, Mandrola, Adam Cifu and Bobby Dubois for the past year or so, you all present great info, some of which I understand, some as a non medical person that I can't interpret. Anyway the question for which I never get a good answer from any PCP is what is low enough to stop taking statins? I'm 80. Thanks for another great article
First a disclaimer, I'm not an MD (and don't even play one on TV). I'm a bit confused about your asking "...what is low enough to stop taking statins?" Do you mean what is a low enough LDL-C? If you get your LDL-C low through taking a statin, you need to stay on it for it to remain low. If you go off the statin, your LDL-C will likely return to baseline. If you want to know how low you should try to get your LCL-C, it seems medical opinions are changing to lower is better, but it still depends. I think the link in first article might be useful. BUT it doesn't mention that statins cross the blood brain barrier, and for those with the APOE4 genotype, and/or a family history of dementia, lipidologist Dr. Thomas Dayspring recommends having your desmosterol tested to make sure it does not go below the 20th percentile (link #2). You can order the test yourself and do it at home. (link #3). I have no affiliation with Boston Heart Health.
I watched my dad have an MI when I was 5 years old. He survived. He was 52. But he was plagued by cardiovascular issues the rest of his life. In total, he had carotid artery surgery, two triple bypass operations, a pig valve and a pacemaker. He eventually died two days after his third CABG surgery. I vowed to take my heart disease risk seriously. Unfortunately, I fell for the “statins are bad” misinformation. I did lower my cholesterol, quit alcohol, lose weight, get in shape and get a full preventative cardiovascular workup. I ran two 70.3 triathlons and many other races for years. I had a cardiologist willing to work with me in my late thirties. I was actually doing pretty well, but I slacked off my lifestyle changes and missed a couple of years of follow-ups after my doctor left her practice. My cholesterol went up. I finally got serious again and got educated from another cardiologist. Realized that a statin not only can reduce cholesterol, but also, since I had a CAC of 70, could make that plaque harden so it was less likely to break off.
I’m now also on a PSK9 inhibitor and my ldl is 40 from 141, LDL-P 407 from 1400. I’m 61 and have stable plaque. I probably avoided a major MI. Thanks modern medicine. I just wish I wasn’t duped early on.
Great post. When you put this topic up as a substack note, I was hoping a full post would come out of it.
You make a fantastic point, that primary prevention statin therapy is scrutinized and controversial in a way that primary prevention BP therapy is decidedly not. Very interesting when you delve into why such a dichotomy exists. Cognitive dissonance is a powerful force for clouding thought, and “skepticism” from the keto crowd due to such cognitive dissonance seems like a plausible causation candidate.
In general, skeptics amuse me when they are skeptical about things that challenge their priors…but are perfectly hook/line/sinker when it comes to things that fit their priors (be it keto, vitamin D, or all manner of other supplements that produce nothing other than expensive urine).
Brilliant post - thank you! I think that without eroding trust in medicine, most people can appreciate that Malhotra's "just over 4 days" comment is misleading (a more palatable term perhaps than references to mis- or disinformation). In my experience, even math-phobic people grasp the concept of variability around means. I believe we should keep nudging people to frame health data this way, since essentialist statements like Malhotra's are so prevalent.
(I didn't follow the Med Twitter debate; apologies if I'm just rehashing points already made there.)
The problem is that it is very difficult to go on a podcast and try to explain the intricacies of research and science to those who have not had the training to properly dissect and understand much of the research that is out there. I find this goes for many "providers" as well. I am including everyone who writes prescriptions as being a provider as I have found many that do not know how to properly reach research papers and are often mislead by poor designs. This is one of the biggest reasons why I never go to "lunch and learns" at the clinic I work at because representatives will only cite bits and pieces of information that sound great and will often present you with colorful charts and graphs, which are misleading to say the least. However, they never tell you about the studies in which the newer medicine did not outperform placebo or in which the gains were of little significance when you take a deeper dive in the actual research. When talking about any medicine or procedure it is essentially all about risk and benefit. Risk and Benefits. We try to maximize benefit and eliminate risk. It's a struggle but the way we do this is through honestly using the scientific process. For example, low dose CT scans for lung cancer screening is an interesting topic of discussion which I will not go on and on about, but again it's about risk and benefit and regarding what classification you will fall into. For example, if you're in the group of people that has a small tumor that could be cancerous then you're going to get lots of benefit. However, if you're the one person who has these and they never find anything you're going to fall into the group who may have had little benefit. However, with all things you rarely know which group you fall into. Of course, it's easier to quit smoking entirely but that's another discussion. The same holds true for statins, anti-hypertensives, anti-depressants etc. As for statins I would agree much of the controversy is based on the lipid theory. In regard to starting statins for those patients who are really reluctant. I often try to "nudge" them by having them taking a statin for a couple days each week and then if they do not have any side effects, I will advise them to take it more often. I find after a while most patients are much more apt to eventually take a statin every day versus telling them to take it every day or not take it at all. There are some patients who will never take it daily but if they can take it 3 to 4 days a week then my thoughts are they likely will have some reduction which is better than nothing. Again, great article.
What a great piece. I really enjoyed reading this. I'm fortunate to not get many statin skeptics in my practice but sadly have known patients who've diet of preventable heart attacks.
I must confess that I had considered that statins were forever in the medical category, “dance until your <backside> falls off,” only to, again, finding myself caught up in the article that precipitated this response. I felt again completely disappointed, and up pops Dr. Katz - fully supported by Dr. Stein (with simply no pejorative intended to anyone with whom I am unfamiliar!) and for once I am convinced beyond a reasonable doubt. Thank you.
Patient's perspective here:
I've never had a nuanced discussed with my PCP about medications (or pretty much anything else). The same is true of pretty much everyone I've discussed this big-picture issue with. So while I appreciate the care that it appears that you and some of the commenters here show with patients, that might be the exception.
As for statins in particular, my experience reinforces the general point I made above: I'm a 61-year-old male, a daily runner for 47 of them, weigh what I did in college, no symptoms of chronic disease. My LDL is high enough that it ranks as "elevated." My PCP has twice (via his employer's message portal, not in person) said this means I should be on statins. No discussion of options, no discussion of how the LDL relates to my HDL and triglyceride numbers (which are in the "excellent" range). He knows I run a lot, so he's not going to recommend being more active. But we've not once discussed diet or any other factors. (I weigh 130, so between that and the running he probably thinks I live on oak bark.)
So I just wanted to provide a little insight why some (who have nothing to do with Paleo, etc.) are skeptical. This guy looks at one number and immediately starts talking about medication. Ideally, I would ask, "Can you show me data on people in my demographic with my numbers and activity level and symptoms, and show that statins made a significant difference in MI risk compared to those who didn't take them?" But come on, I get 15 minutes with him once a year. There's no point in even asking the question.
It stinks that you haven’t been able to have a thoughtful conversation with a doctor about this stuff. Every situation is different but it’s disappointing that you haven’t had the chance to discuss yours in detail
I hear you. It's frustrating but as you probably know, it's more the fault of the system that does not allow more time with patients than the fault of your PCP. That's why I read Substacks like this, and listen to podcasts with lipidologists like Dr. Thomas Dayspring. Though I'm not an MD, I've learned enough to know that atherosclerosis can affect even those with a healthy lifestyle, as both age and genes also play a big role. If you want to know whether or not you have it, I would recommend getting a coronary calcium score, and that will tell you whether you need a cholesterol lowering medication, whether it be a statin or ezetimibe if you're a cholesterol hyperabsorber (see my comment above). In most places, a CAC only costs about $100, although you will likely need a referral. Good luck.
Scott, your post peaked my interest because it is common in my practice and other medical practices. To my knowledge, the data that you are referring to specifically doesn't exist. Couple points to help you decide next steps.
1) Age is the #1 risk factor for heart disease (not modifiable). 2) Elevated cholesterol (hyperlipidemia) is a silent disease until it isn't. 3) Your baseline health status is known (appears ideal or better than most) but genetics are not known (family history is only part of the story).
For endurance athletes (myself included), it is a good idea to not assume that every mile we run is adding to our longevity bucket: https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.125.326011
Maybe a post I made yesterday can help as well: https://substack.com/@jvalicedo/note/p-189593374?r=22vvyk&utm_source=notes-share-action&utm_medium=web
Thank you for this comment and your post you linked to.
I'm definitely not in the running-provides-immunity camp (on this or other medical issues). If I had access to someone with your nuanced knowledge and time, I would eagerly collaborate on an investigation. You don't happen to live in the Portland, Maine area, do you?
You are welcome. My practice is located in northern Michigan.
Just an anecdote. My Dad was in the position you are in (lean, runner, generally heathy life style, high LDL etc). Went on statins (early days of statins) - had muscle soreness, went back to "an even at that time known to be less effective than statins" drug. Died of a heart attack, massive, blockage to his arteries.
(His Drs and he talked a lot - so the "blame" for this can't be placed on easily).
This is only one case, of course, so you shouldn't take this as medical advice - mileage may vary etc.
PS. I like your writing style! well written vignette! Made me smile in spite of the memory.
How high was your dad’s LDL?
Sorry, I don't remember. I can recall that he said he would prefer to be on statins, and if I recall correctly (not certain as this was 35ish years ago), he was a bit conflicted about going back to whatever he had been on before. He had a first heart attack out of the blue, luckily when he got got home from a run. Very luckily, the next door neighbour was some sort of senior nurse.
While he was in hospital that first time, it was very striking that the folks who were in good shape survived much more often than the folks who weren't. (We talked to heart Drs about that, and they said that was the case)...
Anyway, one of my brothers and I who have similar issues (thin, fit, active & high bad cholesterol) are on fairly high doses of statins. We straddle 70 years. Haven't had problems with them..
But mileage varies of course...
I think a contributing factor might be that the average layman is not educated in either research design or in statistics, and I wish these topics (at a basic level) were mandatory in high school. Patients only care about what will happen to THEM, while doctors base intervention decisions on population level data because currently, they don't have a sufficiently accurate prediction model as to who will benefit and who will not. For those with high LDL but hesitant to take a statin, getting a CAC score could help. (Seeing the atherosclerosis in my heart was very motivating!).
As for individualizing treatment decisions, there is one thing that CAN be done (but usually isn't). When I first went on a statin, even a high dose was not enough to sufficiently lower my LDL, and my liver enzymes were elevated. Luckily I listened to a podcast with lipidologist Dr. Thomas Dayspring and learned about the Cholesterol Balance Test from Boston Heart, which can be ordered online from Empower Dx and taken at home. The test indicated that I was a cholesterol hyperabsorber, and thus Ezetimibe would work better for me than a statin (and it has, although I still take a low dose statin, since absorption and production can adapt somewhat in a homeostatic manner). Ezetimibe is as cheap as a statin and without the same side effects, and works better than a statin for the roughly 20% of us who are cholesterol hyperabsorbers. Why don't more doctors seem to know this?
https://www.ahajournals.org/doi/10.1161/JAHA.123.031865
https://bostonheartdiagnostics.com/wp-content/uploads/2023/06/02031115-CBT-Treatment-Algorithm_160108.pdf
It not clear if this test is FDA approved and very skeptical if we can trust this.
Questioning is always good, so kudos to you. Here's my take on that: As for whether the lab produces reliable and valid results, they are CLIA certified and CAP accredited, so the answer is yes, they've been shown to reliably measure what they say they are measuring. As for FDA approval, the Boston Heart Health website states, "This test was developed and its performance characteristics determined by Boston Heart Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration(FDA). The FDA has determined that such clearance is not necessary." Mr. Google verifies that lab developed tests do not require FDA approval. The important point is whether research indicates the results can improve treatment recommendations and outcomes. The pdf that I provided a link to has quite a few research references that do exactly that. In my own experience, my lab results were consistent with my poor response to statins, and my good response to Ezetimibe. I would encourage anybody who is interested to look up the research they provide in their References and decide for themselves, and/or order the test and see if following the test's interpretive recommendations improves your outcomes the way it did with me. Luckily, it is a low risk decision, since both drugs are low risk. And it might just improve your outcomes! Cheers!
https://www.pew.org/en/research-and-analysis/fact-sheets/2021/10/diagnostic-tests-not-reviewed-by-fda-present-growing-risks-to-patients
I agree there are some OTC lab tests that are unreliable (too many false positives and/or negatives) and that's why it's important to choose a lab that is certified and/or accredited. The Pew article talks about risk, and I agree that's important, which is why I stressed that decisions make based on these test results are low risk. That's why they are not required to be FDA approved (link below). There would be no reason to even take the test if you didn't already know you have high LCL-C. Of course, you could just start with a statin and see how it works like I did and if it doesn't work well, up your dose until your liver labs are high like I did. Personally I'm glad I found out about the test, because if I hadn't I would not even know anything about why statins were not very effective for me, or that there was a more effective alternative, since my PCP never even mentioned Ezetimibe. The apparent lack of awareness among PCP's is what bothers me. Keep in mind, safe and useful lab tests might not even seek FDA approval because of the high cost of getting such approval (same link below), but that doesn't necessarily mean they are harmful, as the FDA can still pull them from the market if harm is demonstrated. As for usefulness, that is where the research is important. But since most PCP's don't know about it, it's up to patients to seek this out and then decide for themselves whether to shell out the $99. I was lucky my PCP then agreed to write an Rx for Ezetimibe, but she wouldn't have even suggested it if I hadn't.
https://www.testing.com/articles/commercial-tests-fda-approval/
This is an excellent follow-up to Mandrola’s piece. Your point about the differential treatment of statins and antihypertensives is well taken, and I think you’ve correctly identified why statins get such uneven scrutiny in comparison.
I don’t care to get involved in Med Twitter debates, but these conversations often make their way to the exam room. I never use the word “misinformation” because of the modern baggage it carries. I appreciate that patients are trying to navigate the same difficult world that we are.
Honest conversations with patients about uncertainty, probabilities, and personal values aren’t easy—but they are important and meaningful to both me and the patient.
This stuff can be really hard. And reasonable people can look at the exact same clinical risk scenario and have totally different opinions
This might be the most reasonable article on statins I’ve ever read, great job. I think the combination of heightened distrust of pharma (not without reason in some cases!), not wanting to feel like you are “broken” for needing to be on a medication for life and the lack of evidence that they do harm gives people license to basically say whatever the heck the want to support whatever argument they want. Facts never beat feelings after all!
Fully understand all of those feelings
In my entire life (70) dealing with doctors, including about 6 cardiologists, I have had my blood pressure taken in a manner consistent with guidelines (arm elevated to heart level) one time, so my confidence in doctors is low. They (and their staffers) can’t do the simplest thing properly. I’ve had to sit in awkward silence as two nurse practitioners working in a large hospital network insisted that hydrochlothiazide is potassium sparing. Perhaps medical credibility would be greater if practitioners were more knowledgeable and competent.
I’ve read the studies evaluated by Dr David Diamond who discusses absolute risk vs relative risk. I then had the discussion with my husband’s cardiologist. This was a year and a half in after an aortic dissection. He finally said well, you could try a low carb diet. In 3 months my husband lost 35 lbs and he had a CAC with a low score. My question then is why didn’t he lead with that? We believe that the risk of adverse effects from the statins are greater than the benefits. We cut seed oils and sugar from our diet. I realize everyone is different and has to choose what is right for themselves.
I enjoyed your conversation on the topic.
SO very grateful for this well written, carefully nuanced article that addresses, beautifully, the entire controversy. Thank you for taking the time to write an article that addresses both pro and con sides of the debate. As a health professional I’ve long wanted a balanced piece to give my non-medical friends who believe the blanket idea that all statins are bad for anyone. Merci!
Thank you!
Lies, damn lies and statistics. Or something like that from Mark Twain. In today's world it seems studies can be manipulated in almost any way he who does the study desires. As someone who has been reading you, Mandrola, Adam Cifu and Bobby Dubois for the past year or so, you all present great info, some of which I understand, some as a non medical person that I can't interpret. Anyway the question for which I never get a good answer from any PCP is what is low enough to stop taking statins? I'm 80. Thanks for another great article
First a disclaimer, I'm not an MD (and don't even play one on TV). I'm a bit confused about your asking "...what is low enough to stop taking statins?" Do you mean what is a low enough LDL-C? If you get your LDL-C low through taking a statin, you need to stay on it for it to remain low. If you go off the statin, your LDL-C will likely return to baseline. If you want to know how low you should try to get your LCL-C, it seems medical opinions are changing to lower is better, but it still depends. I think the link in first article might be useful. BUT it doesn't mention that statins cross the blood brain barrier, and for those with the APOE4 genotype, and/or a family history of dementia, lipidologist Dr. Thomas Dayspring recommends having your desmosterol tested to make sure it does not go below the 20th percentile (link #2). You can order the test yourself and do it at home. (link #3). I have no affiliation with Boston Heart Health.
https://www.modernmedlife.com/blog/preventing-heart-disease
https://x.com/Drlipid/status/1916510484200673639
https://empowerdxlab.com/products/product/cholesterol-dx-test?gad_source=1&gad_campaignid=17895710549&gbraid=0AAAAACm7y90ZOSD9swSfXK-e-GK8vha9U&gclid=CjwKCAiAnoXNBhAZEiwAnItcGzR164mCjciszFECquKQMws4nmha3HQlBt96SR6VWSVrrXgEf9QsLRoCy1IQAvD_BwE
Thanks
You betcha! 😁
Every situation is different. Impossible to give a medical opinion without the full clinical context and data review
I watched my dad have an MI when I was 5 years old. He survived. He was 52. But he was plagued by cardiovascular issues the rest of his life. In total, he had carotid artery surgery, two triple bypass operations, a pig valve and a pacemaker. He eventually died two days after his third CABG surgery. I vowed to take my heart disease risk seriously. Unfortunately, I fell for the “statins are bad” misinformation. I did lower my cholesterol, quit alcohol, lose weight, get in shape and get a full preventative cardiovascular workup. I ran two 70.3 triathlons and many other races for years. I had a cardiologist willing to work with me in my late thirties. I was actually doing pretty well, but I slacked off my lifestyle changes and missed a couple of years of follow-ups after my doctor left her practice. My cholesterol went up. I finally got serious again and got educated from another cardiologist. Realized that a statin not only can reduce cholesterol, but also, since I had a CAC of 70, could make that plaque harden so it was less likely to break off.
I’m now also on a PSK9 inhibitor and my ldl is 40 from 141, LDL-P 407 from 1400. I’m 61 and have stable plaque. I probably avoided a major MI. Thanks modern medicine. I just wish I wasn’t duped early on.
Great post. When you put this topic up as a substack note, I was hoping a full post would come out of it.
You make a fantastic point, that primary prevention statin therapy is scrutinized and controversial in a way that primary prevention BP therapy is decidedly not. Very interesting when you delve into why such a dichotomy exists. Cognitive dissonance is a powerful force for clouding thought, and “skepticism” from the keto crowd due to such cognitive dissonance seems like a plausible causation candidate.
In general, skeptics amuse me when they are skeptical about things that challenge their priors…but are perfectly hook/line/sinker when it comes to things that fit their priors (be it keto, vitamin D, or all manner of other supplements that produce nothing other than expensive urine).
Thank you for reading. Always appreciate your comments!
Cherry-picking the literature = misinformation.
Brilliant post - thank you! I think that without eroding trust in medicine, most people can appreciate that Malhotra's "just over 4 days" comment is misleading (a more palatable term perhaps than references to mis- or disinformation). In my experience, even math-phobic people grasp the concept of variability around means. I believe we should keep nudging people to frame health data this way, since essentialist statements like Malhotra's are so prevalent.
(I didn't follow the Med Twitter debate; apologies if I'm just rehashing points already made there.)
Very much appreciate and concur that we should try to frame health data in ways that make sense to normal people
The problem is that it is very difficult to go on a podcast and try to explain the intricacies of research and science to those who have not had the training to properly dissect and understand much of the research that is out there. I find this goes for many "providers" as well. I am including everyone who writes prescriptions as being a provider as I have found many that do not know how to properly reach research papers and are often mislead by poor designs. This is one of the biggest reasons why I never go to "lunch and learns" at the clinic I work at because representatives will only cite bits and pieces of information that sound great and will often present you with colorful charts and graphs, which are misleading to say the least. However, they never tell you about the studies in which the newer medicine did not outperform placebo or in which the gains were of little significance when you take a deeper dive in the actual research. When talking about any medicine or procedure it is essentially all about risk and benefit. Risk and Benefits. We try to maximize benefit and eliminate risk. It's a struggle but the way we do this is through honestly using the scientific process. For example, low dose CT scans for lung cancer screening is an interesting topic of discussion which I will not go on and on about, but again it's about risk and benefit and regarding what classification you will fall into. For example, if you're in the group of people that has a small tumor that could be cancerous then you're going to get lots of benefit. However, if you're the one person who has these and they never find anything you're going to fall into the group who may have had little benefit. However, with all things you rarely know which group you fall into. Of course, it's easier to quit smoking entirely but that's another discussion. The same holds true for statins, anti-hypertensives, anti-depressants etc. As for statins I would agree much of the controversy is based on the lipid theory. In regard to starting statins for those patients who are really reluctant. I often try to "nudge" them by having them taking a statin for a couple days each week and then if they do not have any side effects, I will advise them to take it more often. I find after a while most patients are much more apt to eventually take a statin every day versus telling them to take it every day or not take it at all. There are some patients who will never take it daily but if they can take it 3 to 4 days a week then my thoughts are they likely will have some reduction which is better than nothing. Again, great article.
Fully agree that these are complicated topics
What a great piece. I really enjoyed reading this. I'm fortunate to not get many statin skeptics in my practice but sadly have known patients who've diet of preventable heart attacks.
I’d feel much better about statin efficacy if the CTT would release their raw data.
I must confess that I had considered that statins were forever in the medical category, “dance until your <backside> falls off,” only to, again, finding myself caught up in the article that precipitated this response. I felt again completely disappointed, and up pops Dr. Katz - fully supported by Dr. Stein (with simply no pejorative intended to anyone with whom I am unfamiliar!) and for once I am convinced beyond a reasonable doubt. Thank you.