You Are Being Lied To About Cholesterol & Heart Disease.

A nefarious tale or either incompetence or deception.

“Cholesterol does not cause heart disease.“

“Statins do not prevent heart attacks.”

These are two statements you will hear repeatedly on social media.

Usually made by those who really don’t understand what they are saying but increasingly by doctors who really should know better.

In the middle of this hurricane of noise are people who just want to know what to do so they don’t have a heart attack at a young age.

They don’t give a sh!t about all the social media nonsense.

They just want an answer and a plan.

So here’s the truth.

Most of what these social media ‘experts’ are saying is usually true and is based on peer-reviewed scientific literature.

But….

They are leaving out critical pieces of the story to deceive and confuse you.

So, let’s set the record straight.

1. “Cholesterol doesn’t cause heart disease”.

The argument goes like this.

“If cholesterol causes heart disease, why is it that about half of all patients with a heart attack have normal cholesterol?¹”

Good question.

The pathology that causes heart disease (atherosclerosis) is, by definition, the abnormal retention of a cholesterol particle in the artery wall.

A heart attack is when that plaque ruptures and stops blood flow down the artery.

Cholesterol is an essential part of that process.

But other factors also play a role.

And the more ‘other factors’ at play, the less a role high cholesterol has to play.

Think of it this way.

Say you need a score of more than 10 to have a heart attack, but that score MUST include your cholesterol graded on a 1 to 10 scale.

If you have very high cholesterol all your life, you will easily score >10 with no other factors involved.

But even if your cholesterol score is very small (i.e. low cholesterol), the total score can easily be taken to greater than 10 with other risk factors, including high blood pressure, obesity, inactivity, smoking etc.

This is why when you look at the study I referenced above that ‘Half of all patients with heart attacks have normal cholesterol’, you also find that over 60% were current or former smokers, and 50% had high blood pressure.

Cholesterol is an essential part of the story.

But it's not the only factor that matters.

No reasonable doctor has ever said otherwise.

Are you starting to see the lies?

The problem is they are ‘hidden’ in elements of truth, i.e. scientific studies that make them appear credible.

2. “Statins do not prevent heart attacks.”

Once again, you are being told elements of truth, but the real picture is being carefully hidden from you.

I will start with one of the favourite studies ‘experts’ use to make this argument.

(I use the exact same study to prove the very opposite point, and you will understand why in a second.)

This graph shows the absolute and relative risk reduction for statin therapy in preventing heart attacks (Myocardial Infarction), strokes and preventing death from any cause (All-cause mortality)².

As you can see, statin therapy reduces the risk of heart attacks (myocardial infarction) by close to 30%.

This, of course, sounds impressive, but if you look carefully, you will see the absolute reduction in risk is only 1.3%.

Remember, a 33% relative reduction in risk is when you take someone’s risk from 3% to 2%.

It is at this point you are told that you are being lied to and that statins do not work because they only reduce your risk of a heart attack by 1%.

You are also told you would have to treat 100 people to prevent one heart attack.

This is known as the NNT (Number Needed To Treat), and in many statin studies, it has been as high as 300 or more.

“You see - statins don’t prevent heart attacks.”

What do I have to say to this?

Not much, really.

All of this is correct.

But what you are conveniently Not Told is that this only considers risk over a 4 year period.

That was the average duration of all the studies included in the above study.

And as I have said many times before, “I am not interested in your risk over the next 4 years, I am interested in your risk over the next 40”.

Let’s change the time component here and see what happens to your risk and also the NNT (Number Needed To Treat) to prevent a heart attack.

Here is a typical patient I might see in my clinical practice.

40 year old male with a family history of heart disease.

Overweight but not obese and a systolic blood pressure of 135 mmHg (Not very high but certainly not ideal).

Non-smoker, doesn’t have diabetes and is on no medications.

LDL cholesterol = 4 mmol/l ( 155 mg/dl).

HDL cholesterol = 1.2 mmol/l ( 46 mg/dl).

Let’s have a look at this person’s risk over time and also the benefit of lowering their LDL cholesterol with a statin (Or any cholesterol-lowering medication, for that matter).

At 4 years out, i.e., age 44 and the same time frame the study above examined, you can see this person’s risk of a heart attack is 1%.

This could be reduced to 0.8% with a statin.

For Reference Lp(a) is normal.

Relative Risk Reduction: 20%

Absolute Risk Reduction: 0.2%

Number Needed To Treat: 500!

This doesn't really sound like a good deal, does it?

But we are not interested in 4-year risk. We are interested in 40-year risk.

Let's see what happens at 40 years out to age 80.

For Reference Lp(a) is Normal.

Now, we see a very different picture.

Relative Risk Reduction: 57.6%

Absolute Risk Reduction: 25.7%

Number Needed To Treat: 3.9.

How about we also fix that high blood pressure and get it to less than a systolic of 120 mmHg?

For Reference Lp(a) is Normal.

Relative Risk Reduction: 78.9%

Absolute Risk Reduction: 35.2%

Number Needed To Treat: 2.8.

But statins don’t work, right?

Not if you are only interested in looking at very short-term risk.

Also, all I care about is reducing risk, and if we can do that with lifestyle measures and without using medications, that would be all the better.

If this person described above can implement lifestyle changes to significantly lower their LDL cholesterol and blood pressure without medications, that’s fantastic.

I would prefer if they used lifestyle measures to achieve this goal, but what I care about most is that they actually GET to the goal.

This is what a lot of people online are really advocating for - to use lifestyle measures more.

And I get that. I really do.

We should make every effort to leverage the immense benefits of lifestyle approaches to reduce risk and, if possible, avoid any of the potential adverse effects of medications.

But that is not always possible, and this is where medications play a role.

It is never about Lifestyle Versus Medications.

It is about lifestyle first. Then, medications if needed.

But sadly, this message is rarely conveyed online.

In its place, you will frequently hear:

“Cholesterol does not cause heart disease. “

“Statins do not prevent heart attacks.”

But you are being lied to.

And now you know how.

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1. Statin Eligibility and Outpatient Care Prior to ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc. 2017 Apr 12;6(4):e005333.

2. Evaluating the Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment: A Systematic Review and Meta-analysis. JAMA Intern Med. 2022 Mar 14.