New cholesterol guidelines could significantly reduce statin use

Statins are among the most commonly prescribed cholesterol-lowering drugs in the U.S., but the number of people taking them could soon see a significant drop: Under previous guidelines, 45.4 million adults met the criteria for statin therapy; if the American Heart Association’s latest guidelines are adopted, this number will fall to 28.3 million.¹

This is good news, given that statins do not protect the heart and many people do not need these drugs to lower their cholesterol. At a population level, public health is very likely to improve if fewer people receive statin prescriptions that are damaging to their health in the long term.

Previous statin guidelines lead to 149% increase in use

The most recent cardiovascular disease risk calculator was published in 2013. Known as the Pooled Cohort Equation (PCE), this tool estimated the 10-year risk of heart attack and stroke for people aged 30 to 79, primarily to guide the use of statins.²

Following the publication of the 2013 statin guidelines, the number of people using statins increased by 149%, from 37 million in 2012-2013 to 92 million in 2018-2019. Additionally, between 2008 and 2019, the number of annual statin prescriptions increased from 461 million to 818 million.³ Meanwhile, despite increased use of statins, heart disease has remained the leading cause of death in the United States since 1921.

According to the American Heart Association’s (AHA) 2024 Heart Disease and Stroke Statistics Report, the number of deaths due to heart disease has also increased from the late 2010s to 2020.^Four

In November 2023, the American Heart Association (AHA) and the American College of Cardiology (ACC) will update their cardiovascular risk assessment guidelines, potentially resulting in major changes to statin therapy recommendations. In contrast to the 2013 guidelines, the 2023 AHA Predicting Risk of Cardiovascular Events (PREVENT) equation provides a more comprehensive risk assessment.

Among the differences: the new calculator removes race and replaces it with an individual’s zip code to represent socioeconomic status. PREVENT also separates risk calculations for men and women and includes factors associated with heart disease risk, such as kidney disease, obesity, and hemoglobin A1C.^Five This provides information about an individual’s average blood glucose levels over the past two to three months, according to the AHA.⁶

“The calculator estimates risk of heart attack, stroke and, for the first time, heart failure. The formula is gender and race independent, acknowledges that race is not a biological factor, and can include indicators of social determinants of health.”

This is the first risk calculator to combine indicators of cardiovascular, renal and metabolic health to estimate cardiovascular disease risk. The calculator was developed using health information from more than six million adults from diverse racial, ethnic, socioeconomic and geographic backgrounds.

New guidelines would reduce statin intake by about 40%

A cross-sectional study published in JAMA Internal Medicine suggests that if the PREVENT equation were adopted into national guidelines, there would be about a 40% reduction in people eligible for statin medication.⁷

The study analyzed data from the National Health and Nutrition Examination Survey (2017 to March 2020) and included a weighted sample of 3,785 US adults aged 40 to 75 years with no known atherosclerotic cardiovascular disease (ASCVD).

The researchers found that the average estimated 10-year ASCVD risk using the PREVENT equation was 4.3%, nearly half the 8% risk calculated using PCE. This difference was particularly pronounced for black adults and individuals aged 70 to 75 years. Adoption of the PREVENT equation could reduce the number of adults meeting criteria for primary prevention statin therapy from 45.4 million to 28.3 million, a decrease of approximately 17.3 million.

Of people currently taking statin medications, approximately 4.1 million will no longer meet the medication criteria under PREVENT, and health care providers may instruct patients to stop taking them.

“The PREVIOUS risk equation and the PREVENT equation, which is what we focus on in this study, are meant to give doctors and patients a percentage to start with to decide whether or not it’s worth discussing statins,” lead study author Dr. Timothy Anderson of the University of Pittsburgh Medical Center told STAT. “When you see risk rates cut in half, I think that’s likely to really impact the way doctors and patients talk about these medications.”⁸

Statins are not good for heart health

Even with new guidelines that significantly reduce the number of people eligible for statins, these drugs will continue to do more harm than good for the vast majority of people who take them. Statins have not halted the growing trend of heart disease, and instead increase the risk of health conditions associated with their use, such as diabetes.^9,Ten dementia¹¹ Other features include:

• cancer¹²
• Cataracts¹³
• Musculoskeletal disorders, including muscle pain, weakness, muscle spasms, rhabdomyolysis, and autoimmune muscle disorders¹⁴
• depression¹⁵

Increased health risks aside, the widely held myth that lowering cholesterol with statins improves heart health continues to permeate modern medicine and encourages inappropriate use of statin drugs. The Framingham Study, which began in 1948, involved 5,209 people from Massachusetts.¹⁶ This gave rise to the myth that high total cholesterol is the main risk factor for heart disease.

But the correlation only exists when cholesterol is above 300 milligrams per deciliter (mg/dl): “Very few people have total cholesterol levels that high,” Dr Aseem Malhotra, consultant interventional cardiologist, explained on The Joe Rogan Experience.¹⁷

Another thing that wasn’t widely publicized about the Framingham study was what happened to people in their 50s, 60s and older, in whom lowering cholesterol increased mortality. “So, first of all, the link between cholesterol and heart disease is very weak,” Malhotra says.¹⁸

Malhotra and his colleagues conducted a study to see whether there was a correlation between lowering LDL and total cholesterol and preventing heart attacks and strokes, but they found no clear correlation. “This is based on randomized controlled trial data, so it’s the most robust evidence,” he says.¹⁹

Statins deplete the body’s coenzyme Q10

Your body’s production of Coenzyme Q10 (CoQ10) peaks around age 25 and then begins to decline. By age 65, your body’s production is usually only about half what it was at age 25.²⁰ Aging is not the only factor that can decrease CoQ10 levels: statin drugs are also known to deplete CoQ10.

Statins work by inhibiting an enzyme in the liver called HMG coenzyme A reductase, which inhibits cholesterol production. However, this same enzyme is also involved in the production of CoQ10, leading to its depletion. Depletion of CoQ10 may contribute to the muscle-related side effects commonly associated with statins. It is also worth noting that the LDL cholesterol that statins aim to reduce is the primary carrier of CoQ10 in the bloodstream.^{twenty one}

So if you are taking statins, be aware that they deplete your body’s CoQ10 and inhibit the synthesis of vitamin K2. Younger people can usually take advantage of CoQ10 supplements, but older adults may benefit more from ubiquinol, a more easily absorbed form.

If you are taking a statin, you may need at least 100 milligrams (mg) to 200 mg of ubiquinol or CoQ10 daily. It’s best to consult with your doctor to determine the appropriate dose.

Generally, healthy people only need 30-100 mg per day, while those with health conditions may need 60-1,200 mg per day. If you lead an active lifestyle, exercise frequently, or are under a lot of stress, taking 200-300 mg per day may be beneficial.

Gut bacteria lowers risk of heart disease

To protect your heart health, it’s better to focus on gut health rather than relying on prescription drugs. Evidence suggests that changes in the gut microbiome are linked to cardiovascular disease. Researchers from the Broad Institute, Massachusetts General Hospital, and Harvard University have identified specific gut bacteria that influence cholesterol levels, triglycerides, blood sugar levels, and heart disease risk.^{twenty two,twenty three}

Analysis of the bacterial genomes in the stool samples revealed that a bacterium called Oscillibacter was associated with lower cholesterol levels, lower triglycerides and glucose, and higher high-density lipoprotein (HDL). The scientists also found that Oscillibacter breaks down cholesterol into smaller molecules that don’t increase the risk of heart disease.

“The reduction in cholesterol by Oscillibacter appears to be related to the genes encoding enzymes that break down cholesterol in the intestine, which may reduce cholesterol entering the bloodstream,” the researchers explained.^{twenty four} In fact, improving gut health is a crucial component of heart disease prevention, and a diverse and balanced gut microbiome is essential for overall health.

Cultivating oxygen-intolerant beneficial bacteria, such as the key species Akkermansia, strengthens gut defenses and creates an environment that supports overall health. These beneficial bacteria break down dietary fiber to produce short-chain fatty acids (SCFAs), especially butyrate.

This compound nourishes colonic epithelial cells and strengthens the intestinal barrier. SCFAs also stimulate the production of mucin, which forms a protective layer against harmful bacteria.

A decrease in oxygen-intolerant bacteria can lead to increased intestinal permeability, often referred to as leaky gut syndrome, which allows toxins, undigested food particles, and harmful microbes to enter the bloodstream, potentially causing systemic inflammation and chronic health problems.

Optimizing gut health is a key strategy for protecting heart health

Oxygen-intolerant bacteria are essential for converting indigestible plant fiber into beneficial fats. They thrive in an oxygen-free environment, which requires sufficient cellular energy to sustain them. However, modern factors such as the ingestion of seed oils and exposure to toxins such as endocrine-disrupting chemicals found in plastics impair this energy production, making it difficult to maintain the ideal oxygen-free gut environment.

This may trigger a shift from oxygen-intolerant to oxygen-tolerant species. Importantly, oxygen-tolerant bacteria produce more potent endotoxins. As a result, individuals with more oxygen-tolerant gut bacteria may experience stronger adverse effects on plant carbohydrates due to increased exposure to endotoxins.

However, many people are unaware that septic shock is a major cause of death and that endotoxemia is often the underlying cause. In my opinion, endotoxemia causing septic shock is the number one cause of death, surpassing heart disease and cancer, and what is written on the death certificate is not always the true cause of death.

For example, heart disease and heart failure are common triggers of endotoxemia, so improving mitochondrial function and maintaining a healthy gut ecosystem can help prevent heart disease.

Additionally, if you want to know more about your personal risk of heart disease, don’t rely on total cholesterol or LDL alone. The following tests can give you a more accurate idea of ​​your risk of heart disease:

The potential reduction in statin prescriptions based on the AHA’s updated risk assessment tool further highlights the importance of personalized medicine rather than a one-size-fits-all approach. Heart health does not exist in isolation, but is deeply intertwined with overall health, so a holistic approach to heart disease prevention is necessary.

It is important to consider not only specific traditional risk factors, but also the complex interplay between gut health, mitochondrial function, and various health indicators. This change in perspective may lead to more effective and less invasive strategies to maintain cardiovascular health and reduce the risk of heart disease in the long term.