TL;DR: Statins have become a cornerstone of cardiovascular prevention, largely based on the assumption that lowering LDL cholesterol directly reduces heart attacks and death. This episode revisits the science behind that assumption and asks a more careful question: what does the evidence actually show, and where has the narrative outpaced the data? Click to listen.

Hi everyone,

Cardiovascular medicine has revolved around a simple premise, high LDL cholesterol increases risk. Lower LDL, and you lower heart attacks. Statins emerged as the pharmaceutical solution to that problem and quickly became one of the most prescribed drug classes in history.

The story felt settled. But as with many stories in medicine, the details matter.

Statins are exceptionally good at one thing: lowering LDL cholesterol.

What has been less clear is how consistently that biochemical change translates into meaningful clinical outcomes: fewer heart attacks, fewer strokes, and longer lives, especially in people without existing cardiovascular disease.

Large trials and meta-analyses show modest benefits in select high-risk populations, particularly those with prior heart attacks. But when statins are used for primary prevention, the picture becomes more nuanced. Absolute risk reductions are often small, while side effects like muscle pain, fatigue, metabolic changes are real for many patients.

This raises an uncomfortable but necessary question. Are we treating a number, or are we treating disease?

LDL cholesterol is not a toxin. It is a transport particle, essential for cellular repair, hormone production, and immune function. Cholesterol appears in arterial plaque, but its presence does not prove it initiated the damage.

Increasingly, evidence suggests inflammation, insulin resistance, and metabolic dysfunction precede cholesterol accumulation, not the other way around.

The statin narrative did not emerge from bad intentions. It emerged from urgency, early correlations, and a desire for clear solutions to a complex problem. Over time, guidelines solidified, prescriptions scaled, and nuance was lost.

This episode is not an argument against statins.

For some patients, they are lifesaving. It is an argument for precision, context, and informed consent. Medicine works best when patients understand both the benefits and the limitations of the tools we use.

If we truly want to reduce cardiovascular disease, we must look beyond a single biomarker and address the broader terrain: metabolic health, inflammation, lifestyle, and individualized risk.

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