Cholesterol and Cardiovascular Risk
Hyperlipidemia, or elevated cholesterol, is one of the major contributors of cardiovascular risk. Cardiovascular risk includes heart attack, heart failure, peripheral artery disease, and stroke. Statins have been first line agents for risk reduction for decades and continuously found to be safe and effective. The most infamous symptom is myalgias, or muscle pain/weakness. However, a large meta-analysis of double-blinded randomized control trials of statins vs placebo found that myalgias was reported in 27.1% of patients taking a statin and 26.6% of patients taking placebo (Reith et al., 2022). That means only 0.5% of patients likely had myalgias related to statin therapy and the vast majority was related to “placebo effect.”
This is important because this “statin intolerance” is often a reason patients are not on statin therapy even though it is indicated. The American Heart Association has updated their cardiovascular risk calculator in 2023 with the new PREVENT calculator which is more nuanced and can extrapolate 30-year risk along with 10-year risk. This can help patients look at a “lifetime” risk of cardiovascular disease which can be more helpful than the 10-year risk available previously. Treatment options can then be tailored based on the patient’s preference. Lifestyle modifications are always the first step, but it has generally not been found effective in a large population, especially when statin treatment is so effective. Studies have found that the lower you can reduce your LDL, the better. Every 40mg/dL decrease in LDL reduced your relative risk of cardiovascular events by 20% and all-cause mortality by 10%(Cholesterol Treatment Trialists’ (Ctt) Collaboration, 2010; Besseling et al., 2013). Importantly, this risk reduction continues beyond just 40mg/dL.
For example, say you enter in your information on the PREVENT calculator, your baseline LDL is 170mg/dL, and your 30-year risk for cardiovascular disease is 20%. If you’re able to reduce your LDL to 130mg/dL, you can reduce your 30-year risk from 20% to 16%. If you can reduce it to 50mg/dL, then you can reduce your 30-year risk from 20% to 8%!
I think this is pretty significant. We are in an age where there is more and more exposure to influencers online trying to promote the next big thing in supplements and longevity. I am generally highly suspicious of their claims because they are invested in these supplements, and therefore not impartial and have conflicts of interest. There is no “Big Statin.” Most prescribed statins have been generic medications for decades. There’s only a mountain of evidence from decades of trials showing the efficacy and safety of this class of medication.
Besseling, J. et al. (2013) “LDL Cholesterol Goals in High-Risk Patients: How Low Do We Go and How Do We Get There?,” Drugs, 73(4), pp. 293–301. Available at: https://doi.org/10.1007/s40265-013-0028-0.
Cholesterol Treatment Trialists’ (Ctt) Collaboration (2010) “Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials,” The Lancet, 376(9753), pp. 1670–1681. Available at: https://doi.org/10.1016/S0140-6736(10)61350-5.
Reith, C. et al. (2022) “Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials,” The Lancet, 400(10355), pp. 832–845. Available at: https://doi.org/10.1016/S0140-6736(22)01545-8.