Should You Take A Statin To Lower Your Cholesterol?

So many struggle with this question, but all you need is a framework.

Let’s start with the fact that this is not a yes or no answer.

To answer this question, you need to understand three key factors:

1. What is your baseline risk?

2. Over what time horizon are you looking to reduce risk?

3. What is your attitude toward reducing that risk?

Only when you have a clear idea of those three factors can you decide whether or not to take a medication to lower your LDL cholesterol.

(When it comes to lifestyle strategies to lower LDL cholesterol, I have discussed these before here, but in short, I do not think they are an adequate strategy in isolation for lipid-lowering if you are truly looking to maximise risk reduction.)

I use statins in the question posed above because that is what most people think and, in fact, what they will start with when looking to lower their LDL cholesterol with a medication.

There are multiple medications to lower LDL cholesterol, statin therapy being the most commonly used.

And when it comes to reducing risk, it really doesn't matter which therapy you use.

So, if your issue is with statin therapy specifically and not LDL cholesterol lowering in general, then you have lots of other options¹.

But first, let’s address some common concerns about statin therapy.

1. “Statins cause dementia”.

This one is easy. No, they don’t.

If you believe they do, you are in the dogma business, not the science business.

For a more detailed explanation of why this is the case and why they may, in fact, protect against dementia, you can read a previous post here.

2. “Statins cause diabetes”.

This one is true.

But the devil is in the detail.

In truth, it is really those who are pre-diabetic who likely pull forward their diagnosis by about five days.

But they do not magically take someone who is insulin-sensitive to full-blown type 2 diabetes overnight.

Even those who are pulled forward in their diagnosis of type 2 diabetes still get a significant reduction in the risk of heart disease.

For a more nuanced exploration of this topic, you can read a previous post here.

3. “Statins cause muscle aches and joint pains”.

They do.

But WAY less often than you think.

And even when they do it is likely a function of the nocebo effect rather than the active ingredient of statin therapy. I.e. The act of taking a tablet.

For a more detailed discussion on this topic, you can read a previous post here.

Now that we have those concerns out of the way, we can answer our three key questions.

1. What Is Your Baseline Risk?

This is about estimating your near-term risk of a heart attack.

The most accurate way (But not the only way) to answer this question is whether or not you have plaque in your coronary arteries.

If you already have plaque, your risk of event an event goes up proportional to the amount of plaque you have².

The amount of plaque in your coronary arteries can be estimated by looking directly at your coronary arteries with a cardiac CT and calculating your CAC score.

This also means that if you have a CAC score of 0, you have no calcified plaque in your coronary arteries. If you have a normal CT coronary angiogram, which is an even more detailed assessment, you have no calcified or non-calcified plaque.

In this scenario, your risk of a heart attack over the next 10 years is well under 2%. So, low risk by anyone’s books.

Not zero risk. But very low risk.

In this case, going on a statin or any other LDL cholesterol-lowering medication will reduce your risk of a heart attack by about 25%.

But the key question is 25% of what?

If you have a CAC score of 0, that means going from a 2% risk to a 1.5% risk over the next 5 to 10 years.

Which doesn't sound like a great deal, really.

But if you have a CAC score of 400, it means going from a 26% risk to a 19% risk, which seems far more acceptable.

But always remember, we are not interested in 5-year risk; we are interested in 50-year risk.

This takes us to point number 2.

2. Over What Time Horizon Are You Looking To Reduce Risk?

In my view, 10-year risk estimates are only useful to those aiming to only live another 10 years.

So, for most people. Not that useful.

The period of risk we need to consider is the rest of your life.

Which hopefully will be more than 10 years.

Now, let’s see what happens when we lower LDL cholesterol over this time frame.

Take a 40-year-old male who is overweight but not obese, has a systolic blood pressure of 135 mmHg and an LDL cholesterol of 4.1 mmol/l (158 mg/dl), is a non-smoker and has a family history of heart disease.

Lowering this person’s LDL cholesterol by just 2 mmol/l (77 mg/dl) will still only reduce their 10-year risk by about 1 to 1.5% in absolute risk terms.

But the real difference is out to age 80, where the same person’s risk goes from 50% to 22%, a 28% absolute risk reduction.

If you take the exact same person and now correct their blood pressure into the 120 mmHg systolic range and measure their Lp(a), which, if elevated, changes the potential outcomes dramatically.

Their risk of a heart attack out to age 80 now goes from a 64% risk to an 18% risk.

To accrue these benefits, you need to invest early - just like a pension.

Remember, the time horizon of risk matters way more than people typically consider.

Even with a very low near-term risk, the same person's lifetime risk may be substantially higher.

And so, too, is the potential benefit.

But, these first two points hinge on the third key factor.

3. What Is Your Attitude Toward Reducing That Risk?

When it comes to preventing heart disease, there are no right or wrong answers.

In the end, it comes down to:

“Here are your odds over the rest of your life.

Here is the potential gain with no guarantee of a benefit, but these are the odds.

Do you want to take that bet?”

For some people, it is a clear ‘Yes’.

For others, it is a straight ‘No’.

Neither of these people are right or wrong.

They are just expressing their attitude to the risks and benefits on the table.

I have patients with calcium scores of over 1000 with elevated LDL cholesterol values who choose not to go on any cholesterol-lowering medication.

I strongly encourage them otherwise, but in the end, the decision is their own. I cannot force someone to take a medication.

I have patients with moderately elevated LDL cholesterol who are young and low-risk with almost certainly no evidence of plaque and who choose to aggressively manage their risk with cholesterol-lowering medications.

I suspect some of you reading this think one of these groups is insane.

However, the European Society of Cardiology Guidelines are perfectly clear on this point and agree with BOTH individuals.

“Should you take a statin to lower your cholesterol?”

1. What is your baseline risk?

2. Over what time horizon are you looking to reduce risk?

3. What is your attitude toward reducing that risk?

Only when you have answered these three questions can you answer this question.

There are no right and wrong answers here.

But there will be winners and losers.

“Ladies and gentlemen, place your bets, please!”

---

Would You Like To Attend A Live Workshop With Dr Barrett?

On Saturday, Nov 16th, at 3:00 pm Irish Time, Dr Barrett will host The Heart Health Formula workshop online.

Heart disease is the leading cause of death worldwide, and up to 90% of early heart disease is preventable.

The Heart Health Formula workshop is a blueprint for preventing early heart disease.

Dr Barrett will cover the top 10 things everyone should know about assessing and reducing their risk of heart disease.

The workshop will last 90 minutes, with the first 60 minutes by Dr Barrett speaking live, and the remaining 30 minutes will be dedicated to answering questions that you can ask!

We would love to see you there, but if you cannot make it live, the recording will be available to everyone who registers.

Registration will close at midnight on Friday, Nov 15th.

1. 2022: The Year in Cardiovascular Disease – The Year of Upfront Lipid Lowering Combination Therapy. Archives of Medical Science. 2022;18(6).

2. JACC: Cardiovascular Imaging May 2015, 8 (5) 579-596;