This article was originally posted in the Montreal Gazette.
As far as cardiac risk factors go, few people would argue that high blood pressure or diabetes was benign or that attempts to quit smoking were groundless and unwise. No one argues against the benefits of regular exercise and a healthy diet. But when it comes to cholesterol, some people vociferously argue that high cholesterol has nothing to do with heart disease. That some of the more vocal cholesterol opponents later started saying some very unscientific things about COVID and vaccines should provide some insight into the validity of their position.
To be clear, when we speak about high cholesterol we mean LDL, or “bad” cholesterol, which is the one that leads to atherosclerosis or blocked arteries. The sum total of nearly 50 randomized trials comprising over 300,000 patients shows that cardiovascular benefit ties directly and linearly with the LDL or bad cholesterol in your blood: the lower the cholesterol, the better for your heart. What’s interesting is that the benefit seems to be independent of the mechanism. So it doesn’t matter which medication you take, it only matters how low you go.
Some people out there claim that lowering your cholesterol too much is bad for you. But while you do need some cholesterol for basic biological functions, you can get your LDL cholesterol down to near zero levels without any harm or adverse effects. The reality is that LDL cholesterol does you no favours and dropping it as low as you can pays dividends in reducing your cardiovascular risk.
It’s getting there that’s the challenge. In the not too distant past, statins were the only really effective cholesterol medication available and some patients were very reluctant to take them. Part of the problem was news stories in the popular press and on the internet that cast statins in a bad light and led to people stopping their medication.
Many people worry about side effects like muscle pain, even though this side effect is much less common than the internet would have you believe. When you review all the statin trials done over the years, 27 per cent of the people in studies who received a statin complained of some muscle pain or weakness. But 26.6 per cent of people who received a placebo also complained of the same symptoms, which suggests that these symptoms were due to the nocebo effect. In fact, when you don’t tell people whether they’re getting statins or a placebo, they can’t tell the difference. But when you tell people that they were getting a placebo all along, the muscle pains tend to go away.
Still, muscle complaints post-statins remain common, and many cures or treatments have been proposed over the years. Vitamin D is sometimes touted as a potential preventative treatment, but a recent study in JAMA Cardiology puts the lie to that claim. Researchers gave patients either 2,000 units of vitamin D daily or a placebo and found no difference in muscle side-effects. Restricting the analysis to those who were vitamin D deficient at baseline didn’t improve the outcome, either.
In the not-too-distant past, what to do with patients who had statin symptoms was complicated, as there were no good alternatives. People desperate to avoid prescription medications have tried multiple things like fish oil, cinnamon, garlic, turmeric, plant sterols and red yeast rice. But when tested in a proper randomized study, all of these popular cholesterol-lowering products failed to do the most important thing of all. They failed to lower people’s cholesterol. Only the statin arm of the trial succeeded in reducing people’s LDL.
We now have new, albeit more expensive, injectable medications that can be used as a substitute for statins when people cannot tolerate them. But there is a reason we used statins so widely for so many years. They worked.