Chapter 86
How Well Do Statins Work?
If you start taking medications later in life, you have to bring your LDL cholesterol level below 70 milligrams/deciliter to stop the progression of atherosclerosis. But if we start early enough in life, it is sufficient to lower LDL cholesterol only to 100; that would match data from individual countries showing that at that population average, heart disease is least common. That’s why a health-conscious lifestyle can wipe out about 90 percent of heart attack risk, whereas medications only 20 to 30 percent. But that 90 percent applies only if you keep your LDL low your entire life.
If you take medications later in life in the hope of stopping the progression of the disease, you have to get your LDL below 70; but to undo a whole lifetime of poor diet with medications, you probably have to get it down to about 55. And if the heart disease is so severe that you’ve already had a heart attack and are now trying not to die from the next one, you should push it down to about 30. If you manage that, not only will no new atherosclerotic deposits form, but the existing ones will be stabilized, and they’ll be less likely to rupture and kill you.
How well do statins work?
Why avoid certain foods at all if you can just swallow a pill? I discuss the effectiveness of statin medications in detail at see.nf/statins. The absolute risk reduction is only one percent, meaning that out of 100 people who take a medication like Lipitor for several years, only one prevents a heart attack. The acceptance threshold for taking a cholesterol-lowering medication daily, however, is 25 times that. The dirty little secret, then, is that if patients knew the truth—if they knew how little these drugs actually work—they presumably would not take them. A study on patient expectations titled “Do preventive medications prevent enough?” concluded that there is “at best a lack of communication and patient education, at worst a high degree of misinformation about the benefits of these medications.”
That sounds terribly paternalistic, but hundreds of thousands of lives are at stake here. Put simply: If patients learned the truth, very many would die. More than 30 million Americans take statins. Even if you save only 1 out of 100, that still means that hundreds of thousands of lives would end if everyone stopped taking their statins. As a piece titled “The Prevention Paradox” concluded: “It is sheer irony that informing patients about statins would increase exactly the outcomes the drugs are supposed to prevent.”
Are statins right for you?
If you have already had heart disease or a stroke, taking a statin medication is recommended. Period. Full stop. If you do not have known cardiovascular disease, the decision should depend on your personal risk, and if you know your cholesterol levels and your blood pressure, you can calculate it quite easily. For this, there is, for example, the German Heart Foundation’s online offering (herzstiftung.de/risiko), or you can use the American websites of the American College of Cardiology (see.nf/acc), the Framingham Risk Profiler (see.nf/framingham) or the Reynolds Risk Score (see.nf/reynolds).
I prefer the American College of Cardiology calculator because it calculates not only the current 10-year risk but also the lifetime risk. According to current guidelines, with a 10-year risk under 5 percent you should simply eat a healthy diet, exercise, and stop smoking to lower your numbers, unless something argues against it. If your 10-year risk is 20 percent or higher, it is recommended that you change your lifestyle and also take a statin medication. At 5 to 7.5 percent, lifestyle changes are usually sufficient unless there are factors that increase the risk, and with a value between 7.5 and 20 percent you should add medications. Risk factors your doctor should consider when helping you make your decision include, for example, heart disease or strokes in the family, very high LDL levels (≥ 160 mg/dl), metabolic syndrome, chronic kidney or inflammatory diseases, and persistently high levels of triglycerides (≥ 175 mg/dl), C-reactive protein (≥ 2.0 mg/l), or Lp(a) (≥ 50 mg/dl).
If you’re still not sure whether you should take statins, the American Heart Association guidelines may help you; they recommend having the coronary calcium score measured, even though the U. S. Preventive Services Task Force explicitly says that the available data are insufficient to assess whether the risks of the test do not outweigh its benefits (although it requires only a relatively low radiation dose these days).
How safe are statins?
Studies show that 75 percent of people who are prescribed statins stop taking them. Most cite muscle pain as the main reason. About 72 percent of all statin side effects affect the muscles. Taking supplements with coenzyme Q10 to relieve these muscle symptoms at first seemed like a good idea, but on closer examination it turned out they didn’t help. Usually the symptoms go away when you stop the medication, but they can persist for up to a year. Muscle side effects could also be random or psychosomatic and have nothing to do with the drug. Many clinical studies show that such side effects are rare, although it is possible that these investigations—funded by the drug companies themselves—downplay the side effects.
But even researchers in the studies funded by Big Pharma, who attributed only the fewest symptoms to the statins, found that those taking these drugs were significantly more likely to develop type 2 diabetes than participants randomized to placebo pills. Why? We don’t yet know exactly, but statins could do double harm by both impairing insulin production by the pancreas and reducing insulin’s effectiveness by increasing insulin resistance. Unfortunately, this increased risk persists for years after stopping statins.
What can red yeast rice supplements do?
Supplements made from red fermented rice with a statin-producing mold are not recommended, because “dramatic” differences were found in the active components (for example, 100-fold differences in lovastatin content). In addition, one third of the commercial products tested were contaminated with the kidney-damaging fungal toxin citrinin. In 2021, an updated analysis found that 97 percent of the supplements tested exceeded the safety limits for citrinin, even those labeled “citrinin-free,” thereby posing a “serious problem.”
When you consider the benefit of statins for reducing cardiovascular disease, which is what most people in our country die from, any increase in diabetes risk—the seventh leading cause of death (since Covid, number eight)—will presumably be outweighed by the cardiovascular benefits. Among people taking statins, two additional cases of diabetes mellitus per 1000 patient-years are to be expected, and in that time six and a half cardiovascular events such as heart attacks or strokes are prevented. Of course, this is only seemingly a dilemma. We do not need to choose between heart disease and diabetes. We can address the causes of both diseases with the same changes in diet and lifestyle. The diet that not only stops but reverses the progression of heart disease is the same one that can send type 2 diabetes into remission. A sufficiently healthy plant-based diet can prevent further serious incidents in up to 99.4 percent of patients with severe heart disease.