We have a health care system that is clogged with preventive visits which causes patients with true illness and acute needs to wait or clog up the emergency departments. Dr. Pies send clearly outlines part of the problem in this essay.
There are so many gems in this piece - thank you. I felt bad for JM getting so much push back on X and I couldn't understand why there were so many young folks advocating for and taking lipid lowering drugs. The 30 yr calculator was the last straw for me. Especially, like your point out "Medicalising healthy people and treating their lab results as a disease. This draws people 15 yrs earlier into the Kingdom of the sick" I am one of those people who "prefer to live in the here and now". I am rolling the dice on diet and lifestyle keeping out of the "sick care/drug/procedure" medical complex
You are right. Absolute benefits are clinically non-existent. Yet, the side effects of muscle cramps, increased diabetes and possible contribution to Alzheimer's are ignored. Also, the fact that Big Pharma reduced "normal" Cholesterol levels of 300 to a new arbitrary number of 200 the year after Statins were introduced should raise a red flag of deception. A healthy diet of natural foods and lifestyle of exercise, sunshine and reduced stress are what promote long healthy lives.
The evidence you present is genuinely interesting, but I'm going to need a lot more convincing to disregard the Mendelian randomization research than just saying 'it's observational' as if it were equal to a survey.
As an individual, I care about lifetime risk, not even just 30 year risk. Without addressing and making a serious rejection of the Mendelian randomization, I can't see how one wouldn't think that safe low-dose lipid lowering medications over a lifetime would be beneficial. Safe is a big assumption, but the evidence on many of these seem solid as far as I've been able to assess.
I’m familiar with many friends and acquaintances who detested being medicalized right up until they had the triple bypass, stent or fatal heart attack. Not at 82 but in their 40’s and 50’s. Isn’t it time for bold choices in lipid treatment instead of hand wringing over whether we’re starting too early?
If you follow Attia (which I do), you will know he is 1000% about crushing apoaB as much as possible and for as LONG as possible. Preventing the #1 killer is so easily done, be it statins/BPA/EZ (what i do) or pcsk9i. Then you can focus on the other lifespan limiting diseases.
I have mixed feelings about this. Back in my 20’s the nurses at my employer did a total cholesterol check, it was quite high, saw my doctor and he had me do bloodwork and asked my immediate family get checked. Then punched some information into what I now know is the Framingham risk calculator and dismissed it all. My risk was near zero. This should have been obvious when I told him my age.
Was Lp(a) understood 30 years ago? That would have been more helpful than wasting time for my family.
Some information about my future risk would have been helpful and maybe (this is my responsibility) I would have done more earlier to improve my diet and exercise.
Giving me some guidance on when to come back would have also been valuable. My second doctor at 40 didn’t do much better and finally with my third doctor I got my Lp(a) checked and I am medicating down my LDL. Even this didn’t happen until sometime after I learned about Lp(a) on my own and wanted to know.
I’m one of those that learned about heart disease from Dr Attia but I’ve since found many more reliable sources on Substack, thanks for your time and knowledge.
This yet another reason to lean heavily into natural medicine and focus on pleiotropy and using things we are evolutionarily adapted to, as you don't want to take a 30 year gamble with things that don't have that prior, both regarding efficacy and safety. Patent-based medicine is inherently problematic and will some day be seen as a strange abberation in human history.
Prescribing statins for primary prevention in low risk patients is worse than selling "lottery tickets": tiny chance of benefit if at all (like lottery), definite harms (absent in lottery), no way to know if you benefited after 10-30 years (you know whether you win or lose in lottery) >> ?ethical
Let the patient ask the 3 honest questions before any treatment:
1, What is my chance of benefitting in numbers? NNT
2, What is my chance of being harmed in the same numbers? NNH
3, If 100 people like me take this, how many benefit, how many are harmed, and how many see no change?
And cholesterol is not even the "dominant cause" of ASCVD as attested by PCSK9 inhibitor trial results of miniscule clinical outcome benefit in highest risk patients despite >50% reduction of cholesterol; 80-85% of CV events persist despite cholesterol <30 mg/dL
Statin prescription in low risk patients has satisfied all pre-conditions for eventual medical reversal:
1, logical but untested (extrapolation from high-risk to low-risk)
Fantastic post for which 1 “like” seems woefully inadequate.
I’m very much in line with your skeptical viewpoint on long-term risk reduction. Despite what “feels” like a valid concern for younger people, it is entirely driven by an absence of evidence and a healthy amount of “feels”. It’s precisely the type of thing practitioners of EBM should shy away from.
I also appreciate your visual depiction of hypothetical patients, which clearly shows that smoking cessation and BP control would deliver much more bang in a long term 30 yr primary prevention cohort than lipid lowering. Of course, smoking cessation in particular is much easier said than done…but that still shouldn’t excuse reaching for a Rx pad in its stead.
I’ve always been of the mind that the cholesterol isn’t the problem. The reason for the cholesterol is the problem. Why is your cholesterol high? The cholesterol is there for a reason, right?
Interestingly, I began IV phosphatidylcholine in hopes of reducing my pain from small fiber neuropathy. What happened next? Well, I was able to reduce my morphine from 160 mg to 30 mg. But more importantly to this post, My cholesterol went from 275 to 200. So obviously there are many ways to improve your cholesterol levels if they worry you. But cholesterol isn’t the problem. The reason for the cholesterol is the problem. Cholesterol is the Band-Aid.
How accurate are the data? This is the first question that should come to mind when someone gives you a risk percentage for a given period of time. By necessity most of these figures come from cause of death statistics on death certificates----a notoriously inaccurate source of information. Those that have "faith" in these risk profiles are either naive or have not been in medical practice very long. Trials of risk factor modification have been successful in inverse proportion to the length of the trial. A 30 year timeline will ensure that those pushing a specific strategy of prevention will never be called to account for a failure to show meaningful results. Pharmaceutical companies have learned these lessons and cherry pick a few studies with small but "statistically significant" benefits over a short period. Once the claimed beneficial effect is established then copycat drugs are studied with the simple aim of being "noninferior" to the initial one.
Medicalization of healthy individuals, overdiagnosis, and bias are among my greatest concerns with the system. Thank you for an excellent article. Recommend reading Prescribing by Numbers: Drugs and the definition of disease by Jeremy Greene.
One thing not mentioned is the degree of coercion built into this equation now through pay for performance measures targeting stain use. Truly unethical
I'm not a Dr., but am keenly interested in my health. As I age (I'm a 71 yo tech nerd), I've tracked my health stats closely. I look at my med stats in a collective fashion. Lipids, immunity, glucose, cardio, hormones, etc....together they form an overall health score - similar to a financial credit score.
While an individual stat may be interesting, and could be very important, I look at my data to provide guidance on my total lifestyle, diet and meds/supplements. My context is a +30 year marathon runner, with slightly elevated LDL, but other stats are very good.
In a recent visit with a cardiologist, the Doc laughed at me. Biggest threat to my health/life/lifestyle is injury/falling. Biggest control factor for this is reduced intake of booze. No prescription or medical intervention required. Common sense.....
Would I be in better shape by taking a statin these 30 years? Hard to believe they'd improve my stats. But if my diet / lifestyle were different, statins might have made sense.
Really enjoyed your article. My residents call me "Dr. No" because I hold similar views. And science seems on our side. In the past 50 years we've oversold ourselves and what medicine can do. Personally I'm older-79 and take a statin (evidence base shakey but my HDL is 28 and both parents CAD) but I think my 15 mile daily bike ride and a reasonable diet and BMI of 28 and native low BP are probably more important. Thanks again.
We have a health care system that is clogged with preventive visits which causes patients with true illness and acute needs to wait or clog up the emergency departments. Dr. Pies send clearly outlines part of the problem in this essay.
There are so many gems in this piece - thank you. I felt bad for JM getting so much push back on X and I couldn't understand why there were so many young folks advocating for and taking lipid lowering drugs. The 30 yr calculator was the last straw for me. Especially, like your point out "Medicalising healthy people and treating their lab results as a disease. This draws people 15 yrs earlier into the Kingdom of the sick" I am one of those people who "prefer to live in the here and now". I am rolling the dice on diet and lifestyle keeping out of the "sick care/drug/procedure" medical complex
You are right. Absolute benefits are clinically non-existent. Yet, the side effects of muscle cramps, increased diabetes and possible contribution to Alzheimer's are ignored. Also, the fact that Big Pharma reduced "normal" Cholesterol levels of 300 to a new arbitrary number of 200 the year after Statins were introduced should raise a red flag of deception. A healthy diet of natural foods and lifestyle of exercise, sunshine and reduced stress are what promote long healthy lives.
The evidence you present is genuinely interesting, but I'm going to need a lot more convincing to disregard the Mendelian randomization research than just saying 'it's observational' as if it were equal to a survey.
As an individual, I care about lifetime risk, not even just 30 year risk. Without addressing and making a serious rejection of the Mendelian randomization, I can't see how one wouldn't think that safe low-dose lipid lowering medications over a lifetime would be beneficial. Safe is a big assumption, but the evidence on many of these seem solid as far as I've been able to assess.
I’m familiar with many friends and acquaintances who detested being medicalized right up until they had the triple bypass, stent or fatal heart attack. Not at 82 but in their 40’s and 50’s. Isn’t it time for bold choices in lipid treatment instead of hand wringing over whether we’re starting too early?
Amen! The clinical data is overwhelming that we can prevent ASVCD with simple proven cheap meds. I’ve read 1000+ papers on ascvd.
If you follow Attia (which I do), you will know he is 1000% about crushing apoaB as much as possible and for as LONG as possible. Preventing the #1 killer is so easily done, be it statins/BPA/EZ (what i do) or pcsk9i. Then you can focus on the other lifespan limiting diseases.
I have mixed feelings about this. Back in my 20’s the nurses at my employer did a total cholesterol check, it was quite high, saw my doctor and he had me do bloodwork and asked my immediate family get checked. Then punched some information into what I now know is the Framingham risk calculator and dismissed it all. My risk was near zero. This should have been obvious when I told him my age.
Was Lp(a) understood 30 years ago? That would have been more helpful than wasting time for my family.
Some information about my future risk would have been helpful and maybe (this is my responsibility) I would have done more earlier to improve my diet and exercise.
Giving me some guidance on when to come back would have also been valuable. My second doctor at 40 didn’t do much better and finally with my third doctor I got my Lp(a) checked and I am medicating down my LDL. Even this didn’t happen until sometime after I learned about Lp(a) on my own and wanted to know.
I’m one of those that learned about heart disease from Dr Attia but I’ve since found many more reliable sources on Substack, thanks for your time and knowledge.
This yet another reason to lean heavily into natural medicine and focus on pleiotropy and using things we are evolutionarily adapted to, as you don't want to take a 30 year gamble with things that don't have that prior, both regarding efficacy and safety. Patent-based medicine is inherently problematic and will some day be seen as a strange abberation in human history.
Prescribing statins for primary prevention in low risk patients is worse than selling "lottery tickets": tiny chance of benefit if at all (like lottery), definite harms (absent in lottery), no way to know if you benefited after 10-30 years (you know whether you win or lose in lottery) >> ?ethical
Let the patient ask the 3 honest questions before any treatment:
1, What is my chance of benefitting in numbers? NNT
2, What is my chance of being harmed in the same numbers? NNH
3, If 100 people like me take this, how many benefit, how many are harmed, and how many see no change?
And cholesterol is not even the "dominant cause" of ASCVD as attested by PCSK9 inhibitor trial results of miniscule clinical outcome benefit in highest risk patients despite >50% reduction of cholesterol; 80-85% of CV events persist despite cholesterol <30 mg/dL
Statin prescription in low risk patients has satisfied all pre-conditions for eventual medical reversal:
1, logical but untested (extrapolation from high-risk to low-risk)
2, small absolute benefit (if any) over decades
3, non-trivial cumulative harms
4, reliance on surrogate endpoints
5, industry influence on guidelines
6, mechanistic reasoning replacing evidence
Fantastic post for which 1 “like” seems woefully inadequate.
I’m very much in line with your skeptical viewpoint on long-term risk reduction. Despite what “feels” like a valid concern for younger people, it is entirely driven by an absence of evidence and a healthy amount of “feels”. It’s precisely the type of thing practitioners of EBM should shy away from.
I also appreciate your visual depiction of hypothetical patients, which clearly shows that smoking cessation and BP control would deliver much more bang in a long term 30 yr primary prevention cohort than lipid lowering. Of course, smoking cessation in particular is much easier said than done…but that still shouldn’t excuse reaching for a Rx pad in its stead.
I’ve always been of the mind that the cholesterol isn’t the problem. The reason for the cholesterol is the problem. Why is your cholesterol high? The cholesterol is there for a reason, right?
Interestingly, I began IV phosphatidylcholine in hopes of reducing my pain from small fiber neuropathy. What happened next? Well, I was able to reduce my morphine from 160 mg to 30 mg. But more importantly to this post, My cholesterol went from 275 to 200. So obviously there are many ways to improve your cholesterol levels if they worry you. But cholesterol isn’t the problem. The reason for the cholesterol is the problem. Cholesterol is the Band-Aid.
How accurate are the data? This is the first question that should come to mind when someone gives you a risk percentage for a given period of time. By necessity most of these figures come from cause of death statistics on death certificates----a notoriously inaccurate source of information. Those that have "faith" in these risk profiles are either naive or have not been in medical practice very long. Trials of risk factor modification have been successful in inverse proportion to the length of the trial. A 30 year timeline will ensure that those pushing a specific strategy of prevention will never be called to account for a failure to show meaningful results. Pharmaceutical companies have learned these lessons and cherry pick a few studies with small but "statistically significant" benefits over a short period. Once the claimed beneficial effect is established then copycat drugs are studied with the simple aim of being "noninferior" to the initial one.
Medicalization of healthy individuals, overdiagnosis, and bias are among my greatest concerns with the system. Thank you for an excellent article. Recommend reading Prescribing by Numbers: Drugs and the definition of disease by Jeremy Greene.
Thanks for this refreshing perspective
One thing not mentioned is the degree of coercion built into this equation now through pay for performance measures targeting stain use. Truly unethical
I'm not a Dr., but am keenly interested in my health. As I age (I'm a 71 yo tech nerd), I've tracked my health stats closely. I look at my med stats in a collective fashion. Lipids, immunity, glucose, cardio, hormones, etc....together they form an overall health score - similar to a financial credit score.
While an individual stat may be interesting, and could be very important, I look at my data to provide guidance on my total lifestyle, diet and meds/supplements. My context is a +30 year marathon runner, with slightly elevated LDL, but other stats are very good.
In a recent visit with a cardiologist, the Doc laughed at me. Biggest threat to my health/life/lifestyle is injury/falling. Biggest control factor for this is reduced intake of booze. No prescription or medical intervention required. Common sense.....
Would I be in better shape by taking a statin these 30 years? Hard to believe they'd improve my stats. But if my diet / lifestyle were different, statins might have made sense.
Really enjoyed your article. My residents call me "Dr. No" because I hold similar views. And science seems on our side. In the past 50 years we've oversold ourselves and what medicine can do. Personally I'm older-79 and take a statin (evidence base shakey but my HDL is 28 and both parents CAD) but I think my 15 mile daily bike ride and a reasonable diet and BMI of 28 and native low BP are probably more important. Thanks again.