Statins and Cholesterol: Both Sides

Chapter summary

Cardiovascular disease (CVD) is the world’s leading cause of death. About 40 years ago research linked cholesterol with CVD risk, so drugs to lower cholesterol (statins) were developed.
Statins are most effective as secondary prevention, in people who have already had CVD. Benefit is questionable for people with raised cholesterol but no previous CVD.
The author argues the benefit may not come from lowering cholesterol itself, and that the real culprit may be simple carbohydrates, especially fructose.
Diet and exercise can pretty much eliminate the need for statins, in his view.

Statins block the liver enzyme HMG-CoA reductase, lowering LDL (“bad”) cholesterol and modestly raising HDL.
On average they lower LDL by about 1.8 mmol/L, which is linked to a large fall in cardiac events and a 17% lower stroke risk over the long term.
They also block other processes that depend on mevalonate, which is why side effects occur.

Critics of over-prescribing: A Canadian study found 88% of patients should not have been prescribed statins. Australian statin spending is nearly $1 billion a year, with over 22 million prescriptions. Prof Ric Day said many Australians were prescribed statins needlessly while making no lifestyle changes.
Defenders: Prof Freedman said statins are very effective for known vascular disease and high-risk patients. He said diet and exercise alone can never reach the cholesterol levels statins achieve, though more lifestyle change would mean less heart disease. The Heart Foundation was “shocked” when the ABC ran Catalyst programs questioning statins.
Cost-effectiveness: In the WOSCOPS trial, five years of pravastatin in men without prior heart attack cut health costs and extended quality-adjusted life years.
The author: The story is “not clear cut”.

A long Australian study (White 2013) followed over 9,000 patients with moderate cholesterol (4.0 to 7.0 mmol/L). Reduction in the enzyme Lp-PLA2 accounted for over 60% of the benefit, rather than the cholesterol fall itself.
Cholesterol travels inside lipoprotein particles: big “ships” (HDL) and small “ships” (LDL). Particle size and number may matter more than total LDL, so the simple “LDL bad, HDL good” idea is only half true.
Intermittent fasting, including the 5:2 diet, has been reported to lower cholesterol by one to two points.
Better risk tests: Silverman and colleagues (2013) suggest millions may be over-treated and that a coronary artery calcium scan may identify true risk better.

Oxford researchers (Briggs 2013) modelled a daily apple against a daily statin for 5.2 million eligible UK adults over 50.
Even with 70% compliance, apples might prevent 8,500 deaths a year, and over 12,000 at full uptake. They found a similar population effect.
This is a modelling study, not a trial, and has been criticised as a light-hearted comparison.

If you have had a heart attack or have known vascular disease, statins have strong evidence. Do not stop them without medical advice.
If you have no previous CVD, ask about your total risk, not cholesterol alone.
The cheapest way to reduce CVD in the author’s view: no fructose and lower carbohydrate intake.

Taylor, F., Ward, K. et al. (2011) Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev (1):CD004816.
Savoie, I. and Kazanjian, A. (2002) Utilization of lipid-lowering drugs in men and women: a reflection of the research evidence? J Clin Epidemiol 55(1):95-101.
White, H. et al. (2013) Changes in lipoprotein-associated phospholipase A2 activity predict coronary events and partly account for the treatment effect of pravastatin. J Am Heart Assoc.
McConnachie, A. et al. (2013) Long-term impact on healthcare resource utilization of statin treatment, and its cost effectiveness in the primary prevention of cardiovascular disease: a record linkage study. Eur Heart J.
Briggs, A. and Mizdrak, A. (2013) A statin a day keeps the doctor away: comparative proverb assessment modelling study. BMJ 347:f7267.
Silverman, M. et al. (2013) Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden. Eur Heart J.
Mark, D. (2013) Heart Foundation ‘shocked’ at ABC decision to run Catalyst program on cholesterol drugs. ABC News.
Sydney Morning Herald (2013) Statins offer quick fix for heart, for a price.