A recent reader email asks if the skeptical cardiologist has addressed issues raised by prominent “cholesterol skeptics”:
I read with interest and appreciation your article appearing in MedPage on Omega 3s, and find myself having to inquire if you have ever addressed the cholesterol issue?
I’ve followed Uffe Ravnskov, MD, and cohorts, for years who feel it is a myth perpetuated by big pharma for enormous profits, but I have always had a major degree of skepticism coupled with a nagging uncertainty because I don’t take a statin (age 79, generally good health but with elevated levels of LDL-C, no cardiac events). My understanding is that it is of no benefit in primary prevention, questionable in secondary, no effect on overall mortality, potentially serious side effects, and might even be of benefit in older age.
So I can’t help wondering if you have ever addressed this in any of your blogs (reference please, if so) or might you going forward. Your opinion would be appreciated.
I have addressed this exact question in great detail in a post entitled “Don’t Stop Taking Your Statin Medication Based on the Latest News Headlines” but it has been a few years and I presume that it is not easily found by those like my reader who are confused by seemingly convincing scientific articles from ardent statin deniers and cholesterol skeptics like Uffe Ravnskov.
In 2019 another thoughtful reader raised the same question, this time citing a specific Rasnkov article
Nevertheless I am still confused regarding the exact role of cholesterol in the development of CAD. As a ‘layman’ who is very interested in medical issues and especially in CAD and lipid disorders, I know that a preponderance of scientific research (THE GLAGOV, REVERSAL AND ASTEROID studies for instance) have shown that low LDL (60-40 mg/dl) decreases CVD outcomes significantly and that very low LDL levels (< 60) could generate stabilisation and even regression in coronary plaque burden. On the other hand I am also aware that there are researchers who categorically deny the impact of (high) cholesterol and LDL in the development of CAD, for instance this article (with 107 references!).
https://doi.org/10.1080/17512433.2018.1519391 (LDL-C does not cause cardiovascular disease: a comprehensive review of the current literature in ‘Expert review of clinical pharmacology’, Oct. 2018, Uffe Ravnskov et al.)
The conclusion of the article is: The idea that high cholesterol levels in the blood are the main cause of CVD is impossible because people with low levels become just as atherosclerotic as people with high levels and their risk of suffering from CVD is the same or higher. The cholesterol hypothesis has been kept alive for decades by reviewers who have used misleading statistics, excluded the results from unsuccessful trials and ignored numerous contradictory observations.
I am sure you are familiair with this paper and although I am still a firm believer in the beneficial effect of low LDL, as a ‘layman’ it is hard to comprehend why there is still so much debate regarding this issue. For the general public, as I know from discussions with friends, family members, colleagues and acquaintances, it is hard to get well informed regarding the exact role of cholesterol in cardiovascular health and disease, especially when papers contradict! At first sight the paper mentioned above gives the impression of solid research and with 107 references I must say that I am a bit impressed.Dear Anthony: Can you, as an experienced cardiologist, clarify this contradiction? How is it these days still possible that regarding the question Does (high LDL) cholesterol causes atherosclerosis? doctor A says: yes, absolutely and doctor B says: absolutely not. ? ???
My response in 2019 was
“I totally understand your confusion. This is an area I read constantly in and have since I realized the low-fat dogma for diet was incorrect around 2013. I am a fervent believer in challenging the status quo in nutrition. I’m aware of the publications that are published challenging the LDL hypothesis. After looking at all this and approaching it from an unbiased standpoint I have to conclude that the preponderance of the evidence strongly supports the LDL hypothesis. Rather than point you at still more studies and analyses I would suggest listing to this podcast
Start at 31 minutes when Ethan Weiss, a preventive cardiologist, who I rate as truly unbiased and a free thinker summarizes the approach of Seth Kathiresan to studying the genetics of CAD. Then listen to Kathiresan summarize the different forms of evidence that support causal inference and the LDL hypothesis. It’s a nice summary of the multiple scientific lynchpins of the theory.
My first correspondent responded with two more questions:
Thank you for your reply and link. I read it and appreciated the information, very apropos to my thinking. And I really appreciated your compromise approach. I wish I heard it years ago.
It left me with a couple of questions, one general, one specific:
Does taking a statin reverse build-up? I never see that addressed.
This relates to my second question. Being 79 and no cardiac events but high total cholesterol (e.g., 275) from both high LDL C and high HDL, I’m not sure I should start, given what I read. (I seem to recall I had an ultrasound of my arteries about 10 or so years ago and nothing of major concern was noted.)
Does Taking a Statin Reverse coronary atherosclerosis?
High-intensity statin therapy has been shown by the gold-standard intravascular ultrasound technique to cause regression of atherosclerotic plaque in the coronary arteries. But as I try to emphasize (and which I just wrote about here) to patients the size of the plaque or degree of blockage of the artery is not the major problem.
Statins work on the inflammatory potential of the pimples/plaques thus lowering their tendency to progression and rupture and thereby reducing the risk of a heart attack.
The process of plaque stabilization with statin changes the composition of plaque to a more stable form with more scar tissue and calcium so scores from coronary calcium scans can go up.
Should You Start a Statin at Age >75 Years For Primary Prevention
The benefits of statin therapy are lower in primary prevention and not clearly shown in individuals over age 75. I have discussed this in detail in a post on statins in the elderly. Risks of statin side effects aren’t clearly higher in this age group but the frequent presence of comorbidities and polypharmacy increase side effect possibilities. The approach in these patients is similar to the one I outline in the post reproduced below with Geo, my father-in-law who was on the fence about taking a statin.
As an aside, an ultrasound of the carotid arteries can be read as showing “nothing of concern” but still have significant early plaque.
For the elderly patient, we are often looking at coronary calcium and vascular screening data to “derisk“. A zero CAC and normal vascular study would be a strong argument for no therapy.
Still Skeptically Yours,
-ACP
N.B. The evidence that lowering LDL-C or apo B lowers risk of heart attack and stroke has only grown stronger since 2017 because, in addition to randomized controlled trials showing benefits, we now have Mendelian Randomization studies and additional drugs which lower LDL-C/apo B by mechanisms different from statins which further reduce risk of cardiovascular events.