Why Isn’t Everyone on Cholesterol-Lowering Statin Drugs?

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Since there is benefit to getting our LDL cholesterol as low as possible, why aren’t statins prescribed for everyone even if we start out with optimal levels?

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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.

Intro: In these next few videos I’m going to be covering cholesterol lowering drugs. Like statins, why LDL cholesterol is such a major threat, for whom the benefits of these drugs outweigh the risks, and what we can do to lower our cholesterol naturally.

LDL cholesterol, also known as bad cholesterol, is unequivocally recognized as the principal driving force in the development of atherosclerotic cardiovascular disease, our leading cause of death. Over the decades, we have seen the guidelines shift to lower and lower LDL targets on the basis of clinical trials demonstrating that lower is better––starting in the 1980s with an LDL target of 130 mg/dL, then down to 100 in the 90s, and maybe down to 70 for those at really high risk, and then maybe even down to 55, 40, or 30 over the last decade. Those more recent targets might actually be closer to normal for the human species. Even after we learned to use tools so we could hunt, normal LDL has been in the 50 to 70 range. But today, the average in the Western world is more like 120 mg/dL. No wonder heart disease is our leading cause of death in men and women.

Recently, guidelines started scrapping targets in favor of just pushing for LDL levels to be as low as possible, because the lower the better. No threshold seems to exist below which LDL cholesterol-lowering does not further reduce risk. When it comes to LDL, it’s possible that lower is better for longer—even if you start out at low risk. The risk reduction of major vascular events is independent of the starting LDL cholesterol, meaning that even people starting out with an LDL under 80 had about the same relative risk reduction.

So, even if your LDL is “normal,” even if other heart disease risk factors are considered optimal, it is considered of utmost importance to control it. So, why not just put cholesterol-lowering drugs like statins in the drinking water, like we do fluoride? Why aren’t statins prescribed for everyone? Because of the downsides. There’s the risk of side effects, plus the burden of having to take a pill every day for the rest of your life. So, that’s why these drugs are only recommended for people at relatively high risk of having a heart attack, for whom the pros of cholesterol-lowering outweigh the cons of taking the drug.

Okay, but when it comes to LDL, if “lower is better for longer, and the earlier the better,” and the only reason we’re not giving more drugs is the downsides, what if there were safe, simple, side-effect-free solutions to lowering our cholesterol––for example, eating specific types of healthy foods every day? Well, in that case, regardless if we’re on drugs or not, shouldn’t we utilize every safe no-downside strategy there is to get our LDL down as low as possible? Before I get to all those strategies, let’s answer the on-drugs-or-not question.

According to the latest cholesterol clinical practice guidelines from the American Heart Association and the American College of Cardiology, the number one take-home message is a lifelong heart-healthy lifestyle. Okay, but when do they also recommend drugs? If you have been diagnosed with heart disease, like if you’ve already had a heart attack and are trying to prevent another one, then drugs are considered non-negotiable. Okay, but what about primary prevention––meaning preventing that first heart attack? Well, if you have an LDL of 190 or more, then “Don’t pass go, don’t collect $200,” and go straight to statins. Similarly, if you’re between 40 and 75 and have diabetes, then an LDL of even 70 gets you a statin recommendation. Now, if you don’t have known cardiovascular disease or diabetes, and your LDL is between 70 and 190, then statins are generally recommended if your risk of having a cardiovascular event, like a heart attack or stroke, is 7.5% or more over the next 10 years. Here’s the flow chart for primary prevention, based on age, LDL, diabetes status, and 10-year risk. You can pause and work your way through it.

As you can see, even at a 10-year risk as low as 5%, a statin may be recommended if you have risk-enhancing factors such as high triglycerides or a bad family history. And, if you’re in that intermediate risk category where statins are recommended, but you’re still on the fence, a coronary calcium scan imaging test can be done to help you decide.

How do you figure out what your 10-year risk is? In a previous video I did on the topic, I recommended three common risk calculators, but I have a new favorite, u-prevent.com. That’s just the letter u, dash, prevent (p-r-e-v-e-n-t) dot com. It’s free and endorsed by the European Society of Cardiology. Not only does it give you a 10-year risk estimate, and a lifetime risk estimate, but it estimates how long you may have before the event and, best of all, you can then toggle various treatment options to see what may happen to your risk if you follow them, like what happens if you stop smoking or increase your step count or start a statin.

If this woman does nothing, then her 8.6% 10-year risk would likely merit a statin, but whether or not the overall benefit-harm balance justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even the attending physician. Instead, it is the individual patient who has a fundamental right to decide whether or not to take a drug is worthwhile. It’s your body, your choice; so, let’s go through the pros and cons so you can decide for yourself, next.

Please consider volunteering to help out on the site.

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.

Intro: In these next few videos I’m going to be covering cholesterol lowering drugs. Like statins, why LDL cholesterol is such a major threat, for whom the benefits of these drugs outweigh the risks, and what we can do to lower our cholesterol naturally.

LDL cholesterol, also known as bad cholesterol, is unequivocally recognized as the principal driving force in the development of atherosclerotic cardiovascular disease, our leading cause of death. Over the decades, we have seen the guidelines shift to lower and lower LDL targets on the basis of clinical trials demonstrating that lower is better––starting in the 1980s with an LDL target of 130 mg/dL, then down to 100 in the 90s, and maybe down to 70 for those at really high risk, and then maybe even down to 55, 40, or 30 over the last decade. Those more recent targets might actually be closer to normal for the human species. Even after we learned to use tools so we could hunt, normal LDL has been in the 50 to 70 range. But today, the average in the Western world is more like 120 mg/dL. No wonder heart disease is our leading cause of death in men and women.

Recently, guidelines started scrapping targets in favor of just pushing for LDL levels to be as low as possible, because the lower the better. No threshold seems to exist below which LDL cholesterol-lowering does not further reduce risk. When it comes to LDL, it’s possible that lower is better for longer—even if you start out at low risk. The risk reduction of major vascular events is independent of the starting LDL cholesterol, meaning that even people starting out with an LDL under 80 had about the same relative risk reduction.

So, even if your LDL is “normal,” even if other heart disease risk factors are considered optimal, it is considered of utmost importance to control it. So, why not just put cholesterol-lowering drugs like statins in the drinking water, like we do fluoride? Why aren’t statins prescribed for everyone? Because of the downsides. There’s the risk of side effects, plus the burden of having to take a pill every day for the rest of your life. So, that’s why these drugs are only recommended for people at relatively high risk of having a heart attack, for whom the pros of cholesterol-lowering outweigh the cons of taking the drug.

Okay, but when it comes to LDL, if “lower is better for longer, and the earlier the better,” and the only reason we’re not giving more drugs is the downsides, what if there were safe, simple, side-effect-free solutions to lowering our cholesterol––for example, eating specific types of healthy foods every day? Well, in that case, regardless if we’re on drugs or not, shouldn’t we utilize every safe no-downside strategy there is to get our LDL down as low as possible? Before I get to all those strategies, let’s answer the on-drugs-or-not question.

According to the latest cholesterol clinical practice guidelines from the American Heart Association and the American College of Cardiology, the number one take-home message is a lifelong heart-healthy lifestyle. Okay, but when do they also recommend drugs? If you have been diagnosed with heart disease, like if you’ve already had a heart attack and are trying to prevent another one, then drugs are considered non-negotiable. Okay, but what about primary prevention––meaning preventing that first heart attack? Well, if you have an LDL of 190 or more, then “Don’t pass go, don’t collect $200,” and go straight to statins. Similarly, if you’re between 40 and 75 and have diabetes, then an LDL of even 70 gets you a statin recommendation. Now, if you don’t have known cardiovascular disease or diabetes, and your LDL is between 70 and 190, then statins are generally recommended if your risk of having a cardiovascular event, like a heart attack or stroke, is 7.5% or more over the next 10 years. Here’s the flow chart for primary prevention, based on age, LDL, diabetes status, and 10-year risk. You can pause and work your way through it.

As you can see, even at a 10-year risk as low as 5%, a statin may be recommended if you have risk-enhancing factors such as high triglycerides or a bad family history. And, if you’re in that intermediate risk category where statins are recommended, but you’re still on the fence, a coronary calcium scan imaging test can be done to help you decide.

How do you figure out what your 10-year risk is? In a previous video I did on the topic, I recommended three common risk calculators, but I have a new favorite, u-prevent.com. That’s just the letter u, dash, prevent (p-r-e-v-e-n-t) dot com. It’s free and endorsed by the European Society of Cardiology. Not only does it give you a 10-year risk estimate, and a lifetime risk estimate, but it estimates how long you may have before the event and, best of all, you can then toggle various treatment options to see what may happen to your risk if you follow them, like what happens if you stop smoking or increase your step count or start a statin.

If this woman does nothing, then her 8.6% 10-year risk would likely merit a statin, but whether or not the overall benefit-harm balance justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even the attending physician. Instead, it is the individual patient who has a fundamental right to decide whether or not to take a drug is worthwhile. It’s your body, your choice; so, let’s go through the pros and cons so you can decide for yourself, next.

Please consider volunteering to help out on the site.

Motion graphics by Avo Media

Doctor's Note

This is the first 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 in a “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.

Before we get to foods that can lower LDL cholesterol, let’s look at the pros and cons of cholesterol-lowering drugs

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