Hi Paddy, great piece. Very accessible for non specialists (like myself). What is the research telling us about the ability of statin therapy to address high cholesterol? Are they any downsides to statin therapy?
The evidence for statin therapy to lower cholesterol is very strong. Statins, like all medications, can have side effects but are typically only in a small percentage of people. To complicate matters even further, the research suggests that most of the side effects that people get are not even related to the active ingredient of statin therapy but from the fact of taking a pill. See SAMPSON trial and for muscle effects see https://www.ox.ac.uk/news/2022-08-30-new-study-shows-muscle-pain-not-due-statins-over-90-those-taking-treatment. Hope that helps.
The answer as always is, it depends. And all those factors are what a good clinical consultation involves. It’s all about making bets. As you will understand I can’t give individual clinical advice here however. Unfortunately no certainties in this game.
Thank you for this article and all your writing! If I have had FH my whole life but only got on a statin at 45 (and now repatha), how do I understand my risk of a cardiovascular event? Would I have had incredibly high LDL since birth? Age 10? Age 20?
I can’t give individual advice but in general the longer you are exposed to the risk the greater the likelihood it has translated into earlier cardiovascular disease. If you had coronary disease at this time point which would be young for a female your nearer term risk would be higher.
I'm so glad I found you on Twitter. Your blog posts are thorough yet accessible for laypeople. Do you have any thoughts on carotid artery ultrasounds? I have a CAC of 0, low blood pressure, low APOb and my Lp(a) is 11. My ldl is, unfortunately elevated (150s). The ultrasound showed a monophasic waveform but all other measurements were normal. Due to the waveform, the "indication" was severe CAD and a 10 year risk of 40 percent!!! Should I panic?
Hi Greg - I cannot give individual patient advice here but in general I use Carotid US less than CT CAC etc. The US should be able to clearly state whether there is significant plaque there or not and I think a conversation with your doctor with the report in hand should clarify things.
Love the article. Helps me learn. Two questions: 1) I hear a lot of APOB as a better predictor than LDL cholestorol. I assume the chart still applies? 2) Why wouldn't we put just about everyone (always some exceptions) on statins at a certain age, say 40, or 30?
APOB is a better predictor but the message is the same. APOB article to follow. Re the age question it’s all a matter of preference. I suspect most cholesterol lowering medications will be sold over the counter in the future and the decision will be with the patient mostly.
Thanks. I'm 59 (not sure when it will be OTC). Never had "high" cholesterol, but have family history. Would prefer to stay off/away from drugs, but, if statins are that good and we are talking an "area under the curve" and cumulative impact, it may make sense to me. Talking to my doctor about a Calcium Score or CT-A. I am actually finding places in the Fairfax VA are who publish prices ($125 for the Calcium Score and about $550 for the CT-A). Thanks for the service you provide.
Remember that Ference is a population graph (ecological), which does not generate individual inference. Nor does the particle accumulation theory have any strength because of this, otherwise it would be a strong predictor as well as a flow, and this fails to happen in very many cases.
Thanks Evo. Like all models, none are correct but some are useful. All models for CVD risk prediction suffer from this issue as you well know. But we still have to make a decision. We can update the model with more risk variables, which is what we do in real life. But we still have to make a decision.
Thank you very much for your reply, it is a pleasure to read your thoughts. I think it is relevant to use powerful algorithms, not necessarily with causal markers, which we are already having with a very good AUC, maybe as many authors are proposing 30 years, better than 10 yr. I think it is a drama that many people do not medicate because of the noise of the naysayers, but it is also very relevant to overmedicate.Thanks again.
Some people are disputing the role of high LDL when other markers (e.g. fasting insulin, HDL, triglycerides) are healthy. It would be nice to clear this up using some references to research.
Additionally, I wonder about the linear relationship between cholesterol and plaque and the relationship of risk over time - it feels like something is missing here. How does CAC score relate to this? From what I have seen a stable CAC score (even when relatively high) shows low risk of subsequent death - it's the increasing scores that are problematic. So does that imply that merely having high cholesterol isn't the root problem but that there's some other dysfunction makes the higher LDL levels lead to calcification?
Hi Machiel. As with everything in life, it's never one thing. There is no doubt that having very low insulin levels does decrease your risk of atherosclerosis. However, it doesn't eliminate that risk. I have lots of patients with very low insulin levels and significant coronary artery disease. The key is minimising all risks. Not just one. Re CAC I will likely be doing an article on that in the future.
Love your writing you are continually spot on. Reminded me of what my cardiologist friend quipped: You can never be too rich or have a too low LDL;)
Great article dr paddy food for thought
Love it doc and I love numbers.
More detail in few minutes reading than I’ve been able to get in 3 years from my GP or anyone talking at me.
Never mind just me, time to start taking the kids intake more seriously too.
Had to read the alcohol article first, naturally, but lots of reading tonight, only found you yesterday. Breath of fresh air.
Thanks
Glad you are finding the content useful. Enjoy.
Hi Paddy, great piece. Very accessible for non specialists (like myself). What is the research telling us about the ability of statin therapy to address high cholesterol? Are they any downsides to statin therapy?
The evidence for statin therapy to lower cholesterol is very strong. Statins, like all medications, can have side effects but are typically only in a small percentage of people. To complicate matters even further, the research suggests that most of the side effects that people get are not even related to the active ingredient of statin therapy but from the fact of taking a pill. See SAMPSON trial and for muscle effects see https://www.ox.ac.uk/news/2022-08-30-new-study-shows-muscle-pain-not-due-statins-over-90-those-taking-treatment. Hope that helps.
Very interested in having a discussion with my GP shortly
Thank you for this update and well informed information on taken control over my Owen flight path.😊
Great article Paddy and a refreshing take on risk accumulation + time. Great clarity.
The answer as always is, it depends. And all those factors are what a good clinical consultation involves. It’s all about making bets. As you will understand I can’t give individual clinical advice here however. Unfortunately no certainties in this game.
the 3.2nmol line in the last graph has a mean age of MI in the early 60s.
Shouldn't that age be higher as at that age the CUMULATIVE risk of MI is only 5% (according to right vertical axis) ? thanks
Do you suggest taking statins for a cholesterol of 5.7
Thank you for this article and all your writing! If I have had FH my whole life but only got on a statin at 45 (and now repatha), how do I understand my risk of a cardiovascular event? Would I have had incredibly high LDL since birth? Age 10? Age 20?
I can’t give individual advice but in general the longer you are exposed to the risk the greater the likelihood it has translated into earlier cardiovascular disease. If you had coronary disease at this time point which would be young for a female your nearer term risk would be higher.
I'm so glad I found you on Twitter. Your blog posts are thorough yet accessible for laypeople. Do you have any thoughts on carotid artery ultrasounds? I have a CAC of 0, low blood pressure, low APOb and my Lp(a) is 11. My ldl is, unfortunately elevated (150s). The ultrasound showed a monophasic waveform but all other measurements were normal. Due to the waveform, the "indication" was severe CAD and a 10 year risk of 40 percent!!! Should I panic?
Hi Greg - I cannot give individual patient advice here but in general I use Carotid US less than CT CAC etc. The US should be able to clearly state whether there is significant plaque there or not and I think a conversation with your doctor with the report in hand should clarify things.
Love the article. Helps me learn. Two questions: 1) I hear a lot of APOB as a better predictor than LDL cholestorol. I assume the chart still applies? 2) Why wouldn't we put just about everyone (always some exceptions) on statins at a certain age, say 40, or 30?
APOB is a better predictor but the message is the same. APOB article to follow. Re the age question it’s all a matter of preference. I suspect most cholesterol lowering medications will be sold over the counter in the future and the decision will be with the patient mostly.
Thanks. I'm 59 (not sure when it will be OTC). Never had "high" cholesterol, but have family history. Would prefer to stay off/away from drugs, but, if statins are that good and we are talking an "area under the curve" and cumulative impact, it may make sense to me. Talking to my doctor about a Calcium Score or CT-A. I am actually finding places in the Fairfax VA are who publish prices ($125 for the Calcium Score and about $550 for the CT-A). Thanks for the service you provide.
Is it possible to reduce the amount of plaque in your arteries?
Eliminate entirely? No.
Regress, stabilise and significantly de-risk? Yes.
https://paddybarrett.substack.com/p/reversing-coronary-artery-disease
First class, Paddy. Keep up the good work.
Remember that Ference is a population graph (ecological), which does not generate individual inference. Nor does the particle accumulation theory have any strength because of this, otherwise it would be a strong predictor as well as a flow, and this fails to happen in very many cases.
Thanks Evo. Like all models, none are correct but some are useful. All models for CVD risk prediction suffer from this issue as you well know. But we still have to make a decision. We can update the model with more risk variables, which is what we do in real life. But we still have to make a decision.
Thank you very much for your reply, it is a pleasure to read your thoughts. I think it is relevant to use powerful algorithms, not necessarily with causal markers, which we are already having with a very good AUC, maybe as many authors are proposing 30 years, better than 10 yr. I think it is a drama that many people do not medicate because of the noise of the naysayers, but it is also very relevant to overmedicate.Thanks again.
Thanks for the article!
Some people are disputing the role of high LDL when other markers (e.g. fasting insulin, HDL, triglycerides) are healthy. It would be nice to clear this up using some references to research.
Additionally, I wonder about the linear relationship between cholesterol and plaque and the relationship of risk over time - it feels like something is missing here. How does CAC score relate to this? From what I have seen a stable CAC score (even when relatively high) shows low risk of subsequent death - it's the increasing scores that are problematic. So does that imply that merely having high cholesterol isn't the root problem but that there's some other dysfunction makes the higher LDL levels lead to calcification?
Hi Machiel. As with everything in life, it's never one thing. There is no doubt that having very low insulin levels does decrease your risk of atherosclerosis. However, it doesn't eliminate that risk. I have lots of patients with very low insulin levels and significant coronary artery disease. The key is minimising all risks. Not just one. Re CAC I will likely be doing an article on that in the future.
Thanks! Looking forward to it :)