The Big Stent Scam

You may remember: PCSK9 is the gene that gives some people low LDL levels for a lifetime. For pharmaceutical companies, this natural mutation was an incentive to approach this gene from a pharmaceutical perspective. In see.nf/pcsk9 you can see a detailed discussion of it, but in the end it comes down to the fact that patients can achieve an LDL cholesterol level under 40 through PCSK9 inhibitors, and in some cases even under 15. The heart attack risk drops linearly as LDL falls further and further, even below 10 milligrams/deciliter—and without problems, for example due to impaired synthesis of hormones in the adrenal glands, ovaries, or testes, which the body produces from cholesterol.

It should encourage us that people with extreme PCSK9 mutations that lead to a lifelong reduction of LDL cholesterol to under 20 remain healthy and have healthy children. There is another genetic mutation that gives those affected lifelong LDL cholesterol levels of about 30 milligrams/deciliter, and they have an extraordinarily high life expectancy. Mutations that affect cholesterol are the reason for the so-called longevity syndrome, but that does not mean the medications are also harmless. As a consequence, we should try to lower our LDL cholesterol as far as we possibly can, but with every new class of drugs we need data from much longer follow-ups. So far, so good, but up to now we have only experienced this for a few years. For example, we only learned that statins increase diabetes risk once they had been approved for ten years and millions of people had already been exposed to them. It is also worth mentioning that PCSK9 inhibitors cost about 14,000 US dollars per year.

The Big Stent Scam

Many cardiologists neglect questions about their patients’ lifestyle, perhaps not only because of personal habits and preferences, but also because of their fascination with flashy technical gimmicks and new methods. It’s possible that some feel as though they were trained to be highly specialized fighter jet pilots, ready to go into battle with high-tech weapons—but instead they have to go on a boring diplomatic prevention mission. On the one hand, they miss the chance to treat the actual causes; on the other, certain common cardiology practices do more harm than good. I don’t mean to bash cardiologists. Today, many common medical procedures can cause harm without providing any benefit. Physicians themselves estimate that about one fifth of treatments would not be necessary.

My seven-part video series on stents and angioplasty begins with see.nf/stents. The conclusion: During a heart attack, placing stents can save lives, but hundreds of thousands of these procedures are performed for stable angina—that is, non-emergently. In the past, it was thought this would ease symptoms, but stents neither prolong life nor reduce the risk of a future heart attack, unlike “medical therapy,” which includes lifestyle interventions and taking statins. The Harvard Heart Letter commented: “Stents are for pain; they can’t protect.” But then a famous randomized controlled double-blind study found that stents presumably do not even help with pain.

Wait a minute. A randomized controlled double-blind study with surgeries? In drug tests, you can give participants a sugar placebo pill so they don’t know whether they’re in the treatment group or the control group, but wouldn’t you notice if someone cuts into your groin? Not with a sham operation. Yes, something like placebo surgery really exists. In the study, the researchers cut into all participants, inserted the catheter, and then either placed the stent or did not. Afterward, participants with the sham operations felt just as pain-free as those who had actually been operated on.

If heart attacks are triggered by blocked arteries, why doesn’t it help to physically open them? Because most heart attacks are triggered by narrowings that block less than 70 percent of our arteries; that’s why the deadly plaques are often not visible on an angiogram. Before they rupture, these plaques often do not restrict blood flow, and then they cannot be seen on angiograms or in stress tests. That’s why angioplasty and stents don’t get at the most dangerous lesions, because they don’t change anything about the underlying disease.

Treat the Cause

To drastically lower LDL cholesterol, we have to drastically reduce intake of the three components that drive it up: trans fats, saturated fats, and dietary cholesterol. In the past, partially hydrogenated oils full of trans fats were a common ingredient in industrial foods in the US; meanwhile they are banned and restricted in dozens of other countries around the world. Nowadays, people in three quarters of the countries studied take in trans fats through meat and dairy products. Saturated fats that cause cholesterol to rise are found mainly in animal products and junk food. Dairy products (including pizza) are the main source in the US, followed by chicken, then pastries, pork, and burgers. You can get cholesterol from food only through animal products; by far the most important source is eggs. In second place comes chicken, then beef, dairy products, and pork. No wonder, then, that the key dietary recommendation of the leading cardiology professional societies for the prevention of heart and vascular diseases is to “place more emphasis on consuming plant-based rather than animal-based products.”

Randomized controlled studies with more than 50,000 participants showed that reducing intake of saturated fats leads to fewer cardiovascular diseases, and the less saturated fat you take in, the more clearly cholesterol levels fall. The highly regarded Cochrane Review concluded: “To reduce risks, population groups should continue to consistently reduce their intake of saturated fats.” (Archie Cochrane was a pioneer of evidence-based medicine; his legacy is carried on by the nonprofit organization of the same name, which is highly respected for its high-quality systematic reviews.) The American Heart Association had had enough of the dairy industry’s constant attempts to convince consumers with its “Butter is back” campaign that butter doesn’t harm anyone, so its president published a warning to “once and for all state why the overwhelming majority of carefully conducted scientific research supports reducing saturated fats in the diet.”

The shunning of saturated fats includes tropical oils, which often occur in junk food—for example coconut oil, palm oil, and palm kernel oil—even though animal fats are even worse. As part of the “Animal and Plant PROtein and Cardiovascular Health (APPROACH)” study, participants were randomized so that they consumed either a lot of or a little saturated fat, coming from protein sources such as red meat, white meat, or other products (beans, grains, and nuts). The scientists adjusted the participants’ meals so that the same amount of saturated fat was consumed in all three groups; they standardized the two meat groups with butterfat and the meatless one with tropical oils. And what came of it? With the same amount of saturated fat consumed, cholesterol increased more from red and white meat than from plant protein. Red and white meat were equally bad—just as in randomized controlled studies that did not normalize the saturated fat fractions. Replacing beef with chicken and/or fish also does not yield significantly lower LDL cholesterol values.