How many people would die if we were told the truth about statins?
How Effective Are Statins?
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
In my video on how many doctors paternalistically mislead patients about statin risks and benefits for their own good, I talk about how, for the majority of patients surveyed, the expectation of benefit from drugs like statins is higher than the actual benefit the drugs provide. So, this creates tension between a patient’s right to know and the likely reduction in the chance they’d agree to take it if they knew how little benefit the drug offered. On a population scale, that would be devastating. For example, statins probably prevent tens of thousands of deaths a year in the United States. However, if patients were routinely told the truth, as many as 75% of patients might stop treatment. So, unless we keep everyone in the dark, 30,000 people could die. So what should doctors do? I agree with these doctors that we have to tell the truth, even if it means the patient doesn’t take it and potentially dies as a result. It’s their body, their choice. Of course, I wish this fully-informed consent would extend to telling people about the beneficial role a healthy diet can play. But before we get to that, let’s answer the statins question. Are they worth it? Maybe you’re in the 25% of people who would still take it, even knowing the whole truth. So, what is the whole truth?
We’ve all seen the drug ads, like this one touting atorvastatin—lipitor—as reducing the risk of a heart attack by about a third. But as you can see in the small print, “That means in a large clinical study, 3% of patients taking a sugar pill had a heart attack compared to 2% of patients taking Lipitor.” Going from 3 to 2 is indeed a drop by a third in relative risk, but the drop in absolute risk was only 1%, which sounds less impressive. This is common even in the medical literature—no surprise, since journal articles are often written by drug manufacturers. Now, the 3 to 2% Lipitor drop was over a period of only about three years. These are drugs to be taken over a lifetime; so, the benefits accrue. Over four or five years, the absolute risk reduction might reach 1.3%, but you can see why many patients are not very moved. Even in the studies where people were presented with an idealized tablet with no side effects, more than a third stated they would not consider taking a medication that could drop their five-year absolute risk by 5% or more.
Only about 50% of people would consider taking preventive medications that prolonged their life by less than eight months. The average expected longevity benefit from statins ranges from a few months to a few years, depending on risk. In this patient population here, the expected lifespan gain would be about a year, whereas here’s the distribution of what people would want to take a drug every day for the rest of their lives. About a third said—three months? I’ll take it, whereas about one in 10 said they wouldn’t take pills even if they got to live an extra 10 years or more. That’s why it’s such a personal decision, because we are all over the place in terms of what we’re willing to accept.
Your doctor may not care, though. Physicians were presented with the case of a man with a 7 to 10% risk of dying from cardiovascular disease over the next decade who explicitly told the doctor they only wanted to take a statin if it would increase their lifespan by a certain amount. Some doctors were told the patient demanded at least eight years of life, and others were told the patient only asked for a matter of months, which is actually what they’d gain in real life. Yet 83% of the doctors said they’d recommend it to the patients who unrealistically demanded eight years, which is almost exactly the same percentage recommended by the doctors who were told the patient only wanted a few months. In other words, the doctors were insensitive to patient preferences regarding survival gain.
Now, for primary prevention, trying to prevent your first heart attack, no overall survival benefits have been found. Indeed, only one of eight studies showed that statins actually made you live longer, but presumably that’s because the studies only lasted a few years, and for low-risk populations, the risk of dying from cardiovascular disease in that time may just be a few percent anyway. But such trials do show fewer events, heart attacks and strokes. So, on a public health scale, it would make sense not to just wait for people to have a heart attack before starting them on cholesterol-lowering drugs.
Critics counter that yes, that sounds good, and if statins had these benefits without side effects, then perhaps the decision to start them is understandable. But look, because statins increase our risk of diabetes, these drugs might give as many people diabetes as it does prevent them from having a heart attack or stroke. But the stat they cite is from a combination of primary and secondary prevention trials.
In primary prevention trials, like trying to prevent your first heart attack, there is no increased diabetes risk. You only see that in the secondary prevention trials, where people are trying to prevent their second heart attack, for instance. This might be because their risk of diabetes is higher in general, or they’re using higher doses of statins. Intensive-dose statin therapy is associated with a greater increased risk of new-onset diabetes compared to moderate-dose statin therapy. Of course, intensive therapy also offers more benefits in terms of cardiovascular protection.
Then, if you separate out the primary prevention trials by the populations who have low or high rates of diabetes, regardless of the drug, statins only seem to increase risk among those with high baseline rates. Again, this could be a consequence of running short-term trials in low-risk populations. The big benefit—preventing death—may not show up, but the big downside—like the drug giving you diabetes—may also not show up. But even in the trials that do show increased diabetes, the risk of getting diabetes may be vastly offset by the cardiovascular protection offered from statin therapy. Of course, a healthy diet may reduce the risk of both at the same time, but sticking with the drug discussion before moving on to diet, increased diabetes risk is not the only side effect of statins. What about risks to our muscles, liver, kidney, and brain? I’ll get into all of those, next.
Please consider volunteering to help out on the site.
- Trewby PN, Reddy AV, Trewby CS, Ashton VJ, Brennan G, Inglis J. Are preventive drugs preventive enough? A study of patients’ expectation of benefit from preventive drugs. Clin Med (Lond). 2002;2(6):527-533.
- Diprose W, Verster F. The preventive-pill paradox: how shared decision making could increase cardiovascular morbidity and mortality. Circulation. 2016;134(21):1599-1600.
- Pippin JJ. Primary prevention cardiovascular disease: better than drugs. Arch Intern Med. 2010;170(20):1860-1861.
- Borovcnik M. Risk and decision making: modeling and statistics in medicine – case studies. In: Sriraman B, ed. Handbook of the Mathematics of the Arts and Sciences. 2019:1-36.
- Raittio E, Ashraf J, Farmer J, Nascimento GG, Aldossri M. Reporting of absolute and relative risk measures in oral health and cardiovascular events studies: A systematic review. Community Dent Oral Epidemiol. 2023;51(2):283-291.
- Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet. 2003;361(9364):1149-1158.
- Byrne P, Demasi M, Jones M, Smith SM, O’Brien KK, DuBroff R. 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;182(5):474-481.
- Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart. 2017;103(20):1578-1586.
- Fontana M, Asaria P, Moraldo M, et al. Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility. Circulation. 2014;129(24):2539-2546.
- Halvorsen PA, Aasland OG, Kristiansen IS. Decisions on statin therapy by patients’ opinions about survival gains: cross sectional survey of general practitioners. BMC Fam Pract. 2015;16:79.
- Durai V, Redberg RF. Statin therapy for the primary prevention of cardiovascular disease: Cons. Atherosclerosis. 2022;356:46-49.
- Yourman LC, Cenzer IS, Boscardin WJ, et al. Evaluation of time to benefit of statins for the primary prevention of cardiovascular events in adults aged 50 to 75 years: a meta-analysis. JAMA Intern Med. 2021;181(2):179-185.
- Kostapanos MS, Elisaf MS. Statins and mortality: the untold story. Br J Clin Pharmacol. 2017;83(5):938-941.
- Cai T, Abel L, Langford O, et al. Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses. BMJ. 2021;374:n1537.
- Preiss D, Seshasai SRK, Welsh P, et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA. 2011;305(24):2556-2564.
- Ma W, Pan Q, Pan D, Xu T, Zhu H, Li D. Efficacy and safety of lipid-lowering drugs of different intensity on clinical outcomes: a systematic review and network meta-analysis. Front Pharmacol. 2021;12:713007.
- Masson W, Lobo M, Barbagelata L, Nogueira JP. Statins and new-onset diabetes in primary prevention setting: an updated meta-analysis stratified by baseline diabetes risk. Acta Diabetol. 2024;61(3):351-360.
- Rikhi R, Shapiro MD. Impact of statin therapy on diabetes incidence: implications for primary prevention. Curr Cardiol Rep. 2024;26(12):1447-1452.
Motion graphics by Avo Media
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
In my video on how many doctors paternalistically mislead patients about statin risks and benefits for their own good, I talk about how, for the majority of patients surveyed, the expectation of benefit from drugs like statins is higher than the actual benefit the drugs provide. So, this creates tension between a patient’s right to know and the likely reduction in the chance they’d agree to take it if they knew how little benefit the drug offered. On a population scale, that would be devastating. For example, statins probably prevent tens of thousands of deaths a year in the United States. However, if patients were routinely told the truth, as many as 75% of patients might stop treatment. So, unless we keep everyone in the dark, 30,000 people could die. So what should doctors do? I agree with these doctors that we have to tell the truth, even if it means the patient doesn’t take it and potentially dies as a result. It’s their body, their choice. Of course, I wish this fully-informed consent would extend to telling people about the beneficial role a healthy diet can play. But before we get to that, let’s answer the statins question. Are they worth it? Maybe you’re in the 25% of people who would still take it, even knowing the whole truth. So, what is the whole truth?
We’ve all seen the drug ads, like this one touting atorvastatin—lipitor—as reducing the risk of a heart attack by about a third. But as you can see in the small print, “That means in a large clinical study, 3% of patients taking a sugar pill had a heart attack compared to 2% of patients taking Lipitor.” Going from 3 to 2 is indeed a drop by a third in relative risk, but the drop in absolute risk was only 1%, which sounds less impressive. This is common even in the medical literature—no surprise, since journal articles are often written by drug manufacturers. Now, the 3 to 2% Lipitor drop was over a period of only about three years. These are drugs to be taken over a lifetime; so, the benefits accrue. Over four or five years, the absolute risk reduction might reach 1.3%, but you can see why many patients are not very moved. Even in the studies where people were presented with an idealized tablet with no side effects, more than a third stated they would not consider taking a medication that could drop their five-year absolute risk by 5% or more.
Only about 50% of people would consider taking preventive medications that prolonged their life by less than eight months. The average expected longevity benefit from statins ranges from a few months to a few years, depending on risk. In this patient population here, the expected lifespan gain would be about a year, whereas here’s the distribution of what people would want to take a drug every day for the rest of their lives. About a third said—three months? I’ll take it, whereas about one in 10 said they wouldn’t take pills even if they got to live an extra 10 years or more. That’s why it’s such a personal decision, because we are all over the place in terms of what we’re willing to accept.
Your doctor may not care, though. Physicians were presented with the case of a man with a 7 to 10% risk of dying from cardiovascular disease over the next decade who explicitly told the doctor they only wanted to take a statin if it would increase their lifespan by a certain amount. Some doctors were told the patient demanded at least eight years of life, and others were told the patient only asked for a matter of months, which is actually what they’d gain in real life. Yet 83% of the doctors said they’d recommend it to the patients who unrealistically demanded eight years, which is almost exactly the same percentage recommended by the doctors who were told the patient only wanted a few months. In other words, the doctors were insensitive to patient preferences regarding survival gain.
Now, for primary prevention, trying to prevent your first heart attack, no overall survival benefits have been found. Indeed, only one of eight studies showed that statins actually made you live longer, but presumably that’s because the studies only lasted a few years, and for low-risk populations, the risk of dying from cardiovascular disease in that time may just be a few percent anyway. But such trials do show fewer events, heart attacks and strokes. So, on a public health scale, it would make sense not to just wait for people to have a heart attack before starting them on cholesterol-lowering drugs.
Critics counter that yes, that sounds good, and if statins had these benefits without side effects, then perhaps the decision to start them is understandable. But look, because statins increase our risk of diabetes, these drugs might give as many people diabetes as it does prevent them from having a heart attack or stroke. But the stat they cite is from a combination of primary and secondary prevention trials.
In primary prevention trials, like trying to prevent your first heart attack, there is no increased diabetes risk. You only see that in the secondary prevention trials, where people are trying to prevent their second heart attack, for instance. This might be because their risk of diabetes is higher in general, or they’re using higher doses of statins. Intensive-dose statin therapy is associated with a greater increased risk of new-onset diabetes compared to moderate-dose statin therapy. Of course, intensive therapy also offers more benefits in terms of cardiovascular protection.
Then, if you separate out the primary prevention trials by the populations who have low or high rates of diabetes, regardless of the drug, statins only seem to increase risk among those with high baseline rates. Again, this could be a consequence of running short-term trials in low-risk populations. The big benefit—preventing death—may not show up, but the big downside—like the drug giving you diabetes—may also not show up. But even in the trials that do show increased diabetes, the risk of getting diabetes may be vastly offset by the cardiovascular protection offered from statin therapy. Of course, a healthy diet may reduce the risk of both at the same time, but sticking with the drug discussion before moving on to diet, increased diabetes risk is not the only side effect of statins. What about risks to our muscles, liver, kidney, and brain? I’ll get into all of those, next.
Please consider volunteering to help out on the site.
- Trewby PN, Reddy AV, Trewby CS, Ashton VJ, Brennan G, Inglis J. Are preventive drugs preventive enough? A study of patients’ expectation of benefit from preventive drugs. Clin Med (Lond). 2002;2(6):527-533.
- Diprose W, Verster F. The preventive-pill paradox: how shared decision making could increase cardiovascular morbidity and mortality. Circulation. 2016;134(21):1599-1600.
- Pippin JJ. Primary prevention cardiovascular disease: better than drugs. Arch Intern Med. 2010;170(20):1860-1861.
- Borovcnik M. Risk and decision making: modeling and statistics in medicine – case studies. In: Sriraman B, ed. Handbook of the Mathematics of the Arts and Sciences. 2019:1-36.
- Raittio E, Ashraf J, Farmer J, Nascimento GG, Aldossri M. Reporting of absolute and relative risk measures in oral health and cardiovascular events studies: A systematic review. Community Dent Oral Epidemiol. 2023;51(2):283-291.
- Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet. 2003;361(9364):1149-1158.
- Byrne P, Demasi M, Jones M, Smith SM, O’Brien KK, DuBroff R. 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;182(5):474-481.
- Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart. 2017;103(20):1578-1586.
- Fontana M, Asaria P, Moraldo M, et al. Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility. Circulation. 2014;129(24):2539-2546.
- Halvorsen PA, Aasland OG, Kristiansen IS. Decisions on statin therapy by patients’ opinions about survival gains: cross sectional survey of general practitioners. BMC Fam Pract. 2015;16:79.
- Durai V, Redberg RF. Statin therapy for the primary prevention of cardiovascular disease: Cons. Atherosclerosis. 2022;356:46-49.
- Yourman LC, Cenzer IS, Boscardin WJ, et al. Evaluation of time to benefit of statins for the primary prevention of cardiovascular events in adults aged 50 to 75 years: a meta-analysis. JAMA Intern Med. 2021;181(2):179-185.
- Kostapanos MS, Elisaf MS. Statins and mortality: the untold story. Br J Clin Pharmacol. 2017;83(5):938-941.
- Cai T, Abel L, Langford O, et al. Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses. BMJ. 2021;374:n1537.
- Preiss D, Seshasai SRK, Welsh P, et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA. 2011;305(24):2556-2564.
- Ma W, Pan Q, Pan D, Xu T, Zhu H, Li D. Efficacy and safety of lipid-lowering drugs of different intensity on clinical outcomes: a systematic review and network meta-analysis. Front Pharmacol. 2021;12:713007.
- Masson W, Lobo M, Barbagelata L, Nogueira JP. Statins and new-onset diabetes in primary prevention setting: an updated meta-analysis stratified by baseline diabetes risk. Acta Diabetol. 2024;61(3):351-360.
- Rikhi R, Shapiro MD. Impact of statin therapy on diabetes incidence: implications for primary prevention. Curr Cardiol Rep. 2024;26(12):1447-1452.
Motion graphics by Avo Media
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How Effective Are Statins?
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Content URLDoctor's Note
This is the second video in an extended series on the critically important topic of how to lower LDL cholesterol, the primary driver of our primary killer. In this series, we take a deep dive into how to lower cholesterol through diet. We’ll explore the Portfolio Diet, plant sterols, and cholesterol-lowering supplements, foods, herbs, and spices, then conclude with my Portfolio Plus Powder recipe “cooking” video.
If you don’t want to wait for all the videos to be released over time, we’ve compiled all the information into my latest book, Lower Cholesterol Naturally with Food, available as a softcover, ebook, and audiobook.
If you missed the first video, check out Why Isn’t Everyone on Cholesterol-Lowering Statin Drugs?. The next two videos in the series are The Side Effects Statins: Are They Worth It? and What Is the Best Statin Cholesterol-Lowering Drug?.
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