Cardiovascular disease is the number one cause of death in the Western world. A high cholesterol level in the blood increases the risk of cardiovascular disease. There have been medicines to lower cholesterol in the blood for 30 years. These have developed into one of the most prescribed medicines. Moreover, in the USA, around 40 million people take medication to lower cholesterol. And in the United Kingdom, that figure is almost 8 million.
By Jan Otto Landman MD, PhD
The arteries provide blood supply to the organs. Cholesterols are fats that circulate in our bloodstream. These fats can cause a greasy deposit on the vessel wall. In this vessel wall fatty plaques eventually form, in which calcium can also precipitate (arteriosclerosis). These plaques narrow the blood vessels, ultimately disrupting the blood supply. The organ that depends on this blood (and the oxygen in it) suffers from a lack of oxygen (cramps/acidification in the calves when walking, chest pain during exertion).
A high cholesterol level in the blood means an increased risk of cardiovascular disease, such as heart and cerebral infarction (infarction = tissue death due to lack of oxygen). These serious conditions should therefore be preventable with medications that lower cholesterol in the blood, the so-called statins. Sounds logical.
So lower cholesterol
Based on this assumption, many millions of people worldwide take statins such as simvastine, atorvastine, pravastatin and rosuvastatin. They hope for a longer and healthier life. Because that is ultimately what it is about, living longer and healthier by preventing cardiovascular disease. It is not about the number that represents the cholesterol level in the blood.
In the medical-scientific world, resistance to the mass prescription of statins has been increasing in recent years. This mainly concerns prescribing these drugs to people who do have high cholesterol but do not yet have cardiovascular disease (primary prevention). The value of lowering cholesterol in people who already have cardiovascular disease (secondary prevention), on the other hand, seems to be much more clearly demonstrated.
Usefulness in primary prevention
It has been conclusively shown that statins significantly reduce cholesterol in the blood, by as much as 30% to 50%. However, to date no incontrovertible evidence has been provided for the usefulness of this reduction by statins in people who do have high cholesterol levels but do not have cardiovascular disease (primary prevention).
Various studies into the effects of statins prescribed as primary prevention showed that over a period of 10 years, approximately 7 out of every thousand infarctions are prevented. The other 993 will take place. This means that more than 99% of people who take a statin for 10 years for primary prevention of infarctions actually seem to be doing so for nothing. Shocking statistics, for the more than 99%, especially if they also suffered from side effects. This is also shocking for society, which bears the costs of taking these medications en masse.
An analysis of 18 studies with a total of almost 57,000 participants showed that 5 years of treatment with a statin in patients with high cholesterol but without cardiovascular disease resulted in the prevention of 18 infarctions per 1,000 patients treated. But when risk factors (heredity, high blood pressure, cholesterol level, smoking) were examined, it turned out that in the group of patients with elevated cholesterol but with a low risk, only 6 infarctions per 1000 patients were prevented. In other words: you have to treat 167 of these patients to prevent 1 infarction.
In addition, the use of statins increases the risk of developing diabetes by approximately 1%, count your profit. The side effects of statins are mainly muscle and joint pain, liver and kidney function disorders and fatigue. Almost every doctor who prescribes statins has had patients discontinue treatment due to side effects, especially muscle complaints. However, research sponsored by the pharmaceutical industry hardly shows this to be the case. Strange!
How is that possible?
So we are faced with the problem that it has been convincingly shown that high cholesterol in the blood increases the risk of cardiovascular disease and that at the same time effectively lowering cholesterol with the help of medicines has little effect on preventing these conditions. Having low cholesterol naturally is therefore different from having lower cholesterol due to statins. How can this be explained?
In reality, there is a significantly greater incidence of side effects that require discontinuation of treatment with statin can be explained by the fact that the industry-sponsored studies were mainly conducted in young healthy people and that in reality many elderly people take these medications. Young, healthy people are less likely to suffer from side effects than older people, who are often already taking several other medications.
Various explanations are possible for the limited effect of statins in the primary prevention of cardiovascular disease. The human body is a complex organism. We have only been able to elucidate the metabolic processes to a very limited extent. But if you administer a medication that affects certain steps in cholesterol metabolism, for example by blocking the action of an enzyme, this enzyme will also be blocked in other (metabolic) processes. In this way, we not only treat increased cholesterol, but we also influence other processes in the organism. Subsequently, these can lead to side effects or the cancellation of the positive effect of lower cholesterol.
In addition, it has been found that people treated with a statin started eating more calories and more fat. Weight and body fat in this group therefore increased. This is explained by the reassuring effect of taking a statin. “Oh well, I already take a pill for it, so it’s not that bad anymore.” In addition, statin users also engaged in less physical exertion. This could be (partly) the result of the muscle complaints that statins can cause. The limited effect of statins in the primary prevention of cardiovascular disease could therefore partly be explained by the negative effect on lifestyle factors (diet and physical activity).
It turns out that for years we have been focusing too much on the cholesterol numbers and losing sight of important things such as a healthy lifestyle. It now appears that a deterioration in lifestyle is an important cause of failure of statin therapy. In this light, it is also striking that no study has been conducted that compares the effect of statins with that of a healthier lifestyle. It is probably not attractive to invest money in those types of studies.
Featured: Rosuvastatin and red rice
Recent research (2022) among more than 900,000 statin users showed that rosuvastatin resulted in 15% more cases of severe kidney failure compared to atorvastin. Severe renal failure was defined as a decline in renal function that required renal dialysis or transplantation. Although the number of renal failure cases was small, it was mainly observed in patients with pre-existing reduced renal function who were taking high doses of rosuvastatin. This raises the question: is there still a place for this drug? Especially considering that patients might have access to other, less harmful statins.
Red rice also appears to have a cholesterol-lowering effect. However, this is substantiated by little scientific research. But of course the same applies to red rice as to statins, somewhere it does change something in the metabolism and what effects does this have elsewhere? Furthermore, the aim is, again, not to lower cholesterol in the blood, but to prevent heart disease. And that has certainly not been proven with red rice.
Statins generate hundreds of billions of euros in annual sales worldwide. Therefore, the pressure on science and doctors to promote and prescribe statins is considerable. The usefulness of statins seems unequivocally demonstrated in patients with cardiovascular disease. In people with high cholesterol who do not (yet) suffer from cardiovascular disease, the prescription of statins is still a subject of discussion. Certainly for the group where there are no additional risk factors for cardiovascular disease, the question is whether statins are useful.
For the time being, it seems advisable to exercise caution with statins for the primary prevention of cardiovascular disease. Moreover, with our statin pills we give people the feeling that everything is fine. While ofthen these only have a mrginal effect. As a result, the most important measure, lifestyle change, is completely pushed into the background. We must to more attention to a healthy lifestyle again. Limit the intake of animal fats (meat, dairy), don’t smoke, exercise and take as few pills as possible!
For a personal impression of life in Spain and healthcare, InSpain.news asks Dr. Jan Otto Landman to share his views on medical issues. He has lived and worked in Spain (Costa del Sol) for more than 25 years. His medical practice is in Torremolinos.