Cardiologist on the Over-Prescribing of Statins for Heart Disease

Summary

In this insightful discussion, the speaker challenges the common belief that high cholesterol is a major risk factor for heart disease, citing the Framingham study's limitations and genetic factors. They critique the efficacy of statins in preventing heart attacks and strokes, highlighting the weak correlation found in recent trials and emphasizing statins' anti-inflammatory and anti-clotting properties as the real benefits. The speaker also shares their experience of backlash after publishing research questioning statin use, advocating for transparency and ethical evidence-based medicine.

Takeaways

• 🧬 High cholesterol is not as significant a risk factor for heart disease as previously thought, with the Framingham study showing a significant association only when total cholesterol is over 300 milligrams per deciliter.
• 🧬 Most cholesterol levels are genetic, with 80% being inherited, and only a portion being influenced by diet and lifestyle.
• 🧬 The Framingham study found that very low cholesterol levels (less than 150 milligrams per deciliter) were associated with almost no heart disease, suggesting a genetic factor.
• 🧬 The association between cholesterol and heart disease is weak, with the Framingham study co-director stating that LDL cholesterol levels above 7.8 millimoles per liter are the only ones that predict heart disease.
• 🧬 Statins have been shown to have a small benefit in preventing heart attacks and strokes, but their anti-inflammatory and anti-clotting properties may be more significant than their cholesterol-lowering effects.
• 🧬 The benefits of statins are often overstated, with the actual benefits being quite marginal, such as a 1 in 83 chance of saving a life over a five-year period for someone who has had a heart attack.
• 🧬 The perceived benefits of statins may not be as impactful as other lifestyle changes, such as diet and exercise, which can have a more significant effect on heart health.
• 🧬 There is controversy surrounding the transparency and accuracy of statin research, with concerns about conflicts of interest and the influence of the pharmaceutical industry on study outcomes.
• 🧬 The backlash against questioning the efficacy of statins can be intense, with attempts to discredit researchers and misrepresent their findings.
• 🧬 The medical community has been slow to adapt to new evidence regarding statins, with some researchers losing their positions due to their findings.
• 🧬 Public health advocacy requires resilience in the face of industry pressure and the need for transparency and ethical evidence-based medicine.

Q & A

What is the main topic of discussion in the transcript?

The main topic of discussion in the transcript is the role of statins in lowering cholesterol and their effectiveness in preventing heart disease, as well as the controversy surrounding their use.

What is the Framingham study and why is it significant in the context of cholesterol and heart disease?

The Framingham study is a long-term cardiovascular study that began in 1948 in Massachusetts, which identified various risk factors for heart disease, including high cholesterol. It is significant because it provided early correlations between cholesterol levels and heart disease.

What is the misconception about cholesterol levels and heart disease mentioned in the transcript?

The misconception is that high cholesterol is one of the most important risk factors for heart disease. The transcript suggests that the association between cholesterol and heart disease is weaker than commonly believed.

What does the speaker suggest about the genetic factors influencing cholesterol levels?

The speaker suggests that most cholesterol levels are genetically determined, with 80% of cholesterol being genetic, and that lifestyle and diet can only alter the components of cholesterol, such as triglycerides and HDL.

What is the role of statins according to the speaker?

According to the speaker, statins have a small benefit in lowering LDL cholesterol, but their real benefit in preventing heart attacks and strokes comes from their anti-inflammatory and anti-clotting properties.

What was the outcome of the paper co-authored by the speaker in the BMJ Evidence-Based Medicine?

The paper found no clear correlation between lowering LDL cholesterol and total cholesterol and the prevention of heart attacks and strokes, suggesting that the benefits of statins might be overstated.

What is the speaker's view on the benefits of statins for patients who have had a heart attack?

The speaker believes that the benefits of statins for patients who have had a heart attack are modest at best, with a 1 in 83 chance of saving a life and a 1 in 39 chance of preventing another heart attack.

What was the controversy surrounding the publication of the paper in the BMJ?

The controversy involved a call for retraction of the paper by Professor Sir Rory Collins, a leading statin researcher, due to alleged errors regarding statin side effects. The BMJ eventually subjected the paper to an independent review.

What was the outcome of the independent review of the paper in the BMJ?

The independent review panel concluded unanimously in favor of the paper's authors, with no call for retraction, thus supporting the integrity of their research and findings.

What does the speaker suggest as an alternative to the mass prescription of statins?

The speaker suggests focusing on lifestyle changes such as diet and exercise, which can have a more significant impact on heart health than statins, and advocating for transparent communication and ethical evidence-based medicine.

What is the speaker's stance on the transparency and conflicts of interest in statin research?

The speaker is critical of the lack of transparency and potential conflicts of interest in statin research, particularly when funded by the drug industry and when data is kept confidential.

Outlines

00:00

🧬 Cholesterol and Heart Disease Misconceptions

The speaker clarifies misconceptions about cholesterol's role in heart disease, referencing the Framingham study which identified risk factors like high cholesterol. However, they note that the correlation is weak, especially for total cholesterol levels under 300 mg/dL, and that most cholesterol levels are genetically determined. The speaker also discusses the genetic condition familial hyperlipidemia and the lack of heart disease in people with naturally low cholesterol levels. They emphasize that the association between cholesterol and heart disease is not as strong as commonly believed, and that the benefits of lowering cholesterol with statins are often overstated.

05:01

💊 The Reality of Statin Benefits and Controversy

This paragraph delves into the actual benefits of statins, revealing that their impact on life expectancy and heart attack prevention is minimal, with a best-case scenario benefit of 1 in 83 for saving a life and 1 in 39 for preventing a further heart attack. The speaker criticizes the over-prescription of statins, especially post-heart attack, and the lack of transparency about the true benefits. They recount a controversy surrounding the publication of their research in the British Medical Journal, which questioned the validity of statin benefits and side effects, leading to a threatened retraction and a public debate with a leading statin researcher, Professor Sir Rory Collins.

10:02

🛡️ Standing Firm on Statin Research and Public Health Advocacy

The speaker recounts the backlash and smear campaign they faced for their research on statins, including losing their job and the threat of a retraction of their published work. Despite an independent review that upheld the integrity of their research, the experience was described as challenging and stressful. The speaker emphasizes the importance of ethical, evidence-based medical practice and the need for transparency in communicating medical evidence. They also highlight the influence of pharmaceutical funding on research and the potential for conflicts of interest, advocating for a focus on lifestyle changes as a more effective prevention for heart disease.

Keywords

💡Statins

Statins are a class of drugs that inhibit the enzyme HMG-CoA reductase, which is involved in the production of cholesterol in the liver. They are commonly prescribed to lower blood cholesterol levels and reduce the risk of cardiovascular disease. In the video, the speaker discusses the misconceptions about the effectiveness of statins in lowering cholesterol and preventing heart disease, emphasizing that their benefits have been overstated and their side effects underreported.

💡Cholesterol

Cholesterol is a waxy, fat-like substance that is essential for the body's functions, including the production of hormones, vitamin D, and cell membranes. The script discusses the complex relationship between cholesterol levels and heart disease, highlighting that high cholesterol is not as strongly correlated with heart disease as previously thought, and that most cholesterol levels are genetically determined.

💡Framingham Study

The Framingham Study is a long-term, ongoing cardiovascular study that began in 1948 in Massachusetts. It has been instrumental in identifying risk factors for heart disease, including cholesterol levels. The speaker critiques the study's findings, noting that the association between cholesterol and heart disease was only significant at very high levels and that the study's conclusions have been misinterpreted.

💡Familial Hyperlipidemia

Familial hyperlipidemia is a genetic condition characterized by very high levels of cholesterol in the blood. The speaker mentions this condition to illustrate that some individuals with extremely high cholesterol levels do not necessarily develop heart disease, suggesting that cholesterol levels alone may not be a reliable predictor of heart disease risk.

💡HDL Cholesterol

HDL cholesterol, often referred to as 'good cholesterol,' is a type of cholesterol that is thought to help remove other forms of cholesterol from the bloodstream, potentially reducing the risk of heart disease. The script discusses HDL in the context of the total cholesterol to HDL ratio, which is considered a better indicator of heart disease risk than total cholesterol levels alone.

💡LDL Cholesterol

LDL cholesterol, known as 'bad cholesterol,' is a type of cholesterol that can build up in the walls of arteries, potentially leading to heart disease. The speaker challenges the notion that lowering LDL cholesterol through statin use significantly reduces heart disease risk, citing evidence that the correlation is weak.

💡Anti-inflammatory

Anti-inflammatory refers to the property of reducing inflammation in the body. The speaker explains that statins have anti-inflammatory effects, which may contribute to their heart disease prevention benefits, independent of their cholesterol-lowering effects.

💡Anti-clotting

Anti-clotting refers to the ability to prevent the formation of blood clots, which can reduce the risk of heart attacks and strokes. The script mentions that statins have anti-clotting properties, which may be one of the mechanisms by which they provide some cardiovascular benefits.

💡Evidence-based Medicine

Evidence-based medicine is an approach to medical practice that emphasizes the use of rigorous scientific research to guide clinical decisions. The speaker advocates for evidence-based medicine throughout the script, critiquing the over-prescription of statins and calling for greater transparency and accuracy in medical research and communication.

💡Randomized Control Trial (RCT)

A randomized control trial is a type of scientific experiment that compares the effects of an intervention (such as a drug) against a control group, often receiving a placebo. The speaker cites RCTs as the most robust form of evidence and uses them to argue that the benefits of statins in preventing heart attacks and strokes are not as significant as commonly believed.

💡Conflict of Interest

A conflict of interest arises when a person's professional judgment or actions may be influenced by a personal or financial relationship. The script discusses conflicts of interest in medical research, particularly in relation to the funding of statin research by the pharmaceutical industry, suggesting that such conflicts may bias research findings and influence medical practice.

Highlights

Statins work by lowering cholesterol, but their benefits are often misunderstood.

High cholesterol is considered a major risk factor for heart disease, but the association is not as strong as previously thought.

The Framingham study identified risk factors for heart disease, including high cholesterol, but the correlation is weak unless cholesterol is over 300 mg/dL.

Most cholesterol levels are genetic, with 80% being determined by genetics.

People with genetically low cholesterol tend not to develop premature heart disease.

The benefits of statins are not as significant as once believed, with a weak correlation to preventing heart attacks and strokes.

Statins have anti-inflammatory and anti-clotting benefits, which may contribute to their effectiveness in preventing heart attacks and strokes.

The benefits of statins are often exaggerated, with a 1% benefit for low-risk patients and a 1 in 83 chance of saving a life for high-risk patients.

The life expectancy increase from taking statins after a heart attack is minimal, adding just over four days.

The reduction in heart disease death rates is not significantly attributed to statins, according to European studies.

The backlash against the publication questioning statin benefits was significant, leading to job loss and public scrutiny.

The British Medical Journal faced pressure to retract articles questioning statin benefits but ultimately did not.

The panel reviewing the articles found no reason for retraction, upholding the credibility of the authors.

There is a call for transparency, ethical evidence-based medicine, and a focus on lifestyle changes rather than medication.

Conflicts of interest in statin research have been highlighted, with concerns about the influence of pharmaceutical funding.

The importance of a thick skin and perseverance in advocating for evidence-based medicine and public health is emphasized.

Transcripts

The Joe Rogan Experience can you please

tell us like what is the mechanism how

do statins work and what does it do to

lower cholesterol yeah

so for many years there's been this

misconception

the high cholesterol is one of the most

single one of the most important risk

factors for development heart disease so

I broke down the data and I've published

a lot on this stuff to look at it

properly and Joe this uh the the

association of uh cholesterol and heart

disease came from something called the

Framingham study which was in

Massachusetts started in 1948 carried on

for several decades where they followed

up 5 000 people and many risk factors

for heart disease came from that

correlations which were then validated

like things like type 2 diabetes and

high blood pressure even smoking and

high cholesterol

now what's interesting about Framingham

is when you look at the associations of

total cholesterol and heart disease it

was only there when your total

cholesterol the significant Association

was only there if it was over 300

milligrams per deciliter very few people

have total cholesterol that high and we

have to also understand that most of

your cholesterol is genetic eighty

percent of the cholesterol is genetic 80

80 since it's since I've because

cholesterol is a really important

molecule in the body it's not just a

it's you know important for maintaining

cell uh cell cell membranes it's

important role in the immune system

um hormones hormones vitamin D synthesis

all of that stuff right so it's genetic

you can alter it with your diet the

components of it something called

triglycerides and HDL so-called good

cholesterol right but so the total

cholesterol was not a very good

indicator so if it was very very high

there was Association but that's in

what's interesting about that is though

most almost all of those people had a

genetic condition which gave them very

very high levels of cholesterol it's

called familial hyperlipidemia affects

one into 250 people right and then at

the very other end from Framingham the

very low levels of cholesterol less than

150 milligrams of desolator or four

millimoles in in European terminology

there was almost no heart disease so

again there's genetic factors there and

so basically people with genetically low

cholesterol tend to not develop

premature heart disease

another interesting caveat most of that

data on the development heart disease

was only up to people who were 50 or 60.

and what wasn't publicized is that once

you hit 50 as your cholesterol dropped

in Framingham

your mortality rate increased never

really discussed so I looked at all of

this so that's interesting

but I think the thing that really

um sort of was a nail in the coffin for

me and understanding the association of

cholesterol and heart disease was very

weak

was William castelli who is one of the

co-directors of Framingham cardiologist

in 1996 did a full summary of Framingham

and he said this he said unless you

because you know you're going to talk

about you may be thinking okay hold on

there's good cholesterol and bad

cholesterol so he specifically focused

on what we call LDL bad cholesterol and

he said unless your LDL cholesterol is

above 7.8 millimoles per liter which is

something like

um

Joe it's probably a yeah at least 300

pretty much three around 300 milligrams

per deciliter it has no value in

isolation in predicting heart disease so

what they determined from framing them

was your risk of heart disease as one of

the risk factors was something was your

total cholesterol divided by your HDL

the good cluster or the ratio

so that's the first thing so the

association of cholesterol and heart

disease is quite weak first and foremost

the second question is

when you try and prove that there is a

biomarker that is causal in heart

disease you want to show that if you

lower it

then there is a difference in heart

attacks and strokes for example

and only in 2019

more recently

um I co-authored a paper in bmj

evidence-based medicine with two other

cardiologists and what we did was we

looked at all the drug trials at

lowering cholesterol

to find out is this true when you look

at in totality not cherry-picked

evidence is there a correlation with

lowering LDL cholesterol and total

cholesterol and preventing heart attacks

and strokes and this is based upon

randomized control trial data so this is

the most robust evidence you can get Joe

no clear correlation it was BS the whole

thing was BS in that sense like it's a

very weak if anything

so that means so then the next question

is well hold on how do statins work and

that's the question you asked me earlier

and it's a great question it's a really

important one statins do have a small

benefit but one of the properties of

statins which isn't talked about is they

have anti-inflammatory and anti-clotting

benefits so even though they lower LDL

cholesterol the real benefit in

preventing heart attacks and strokes is

through that mechanism but when you

break it down as I said before your risk

is you know the benefits are about one

percent if you're low risk of heart

disease but if you've had a heart attack

and many patients I see have had heart

attacks and they've got automatically

put on statins and that cardiologists

read even checked their cholesterol

because in the Cardiology Community we

kind of knew that was like it doesn't

matter what your cholesterol is let's

put them on a Statin because the trials

show there are benefits but what are

those benefits when you break them down

in absolute terms this is really crucial

and important and this isn't Cherry

Picked stuff this is what all the

evidence shows

and it's been peer reviewed Etc if

you've had a heart attack

patient comes to me Doc shall I carry on

the Statin or I've been put on the

Statin or I'm getting side effects I say

to listen let's just let me just explain

to you the benefits first so that you're

not you don't have an exaggerated fear

of stopping a Statin and you also don't

go around with the illusion of

protection thinking that's the only

thing I need to do now

over a five-year period if you take your

Statin religiously and don't get side

effects right because remember the

trials took out people with side effects

so best case scenario

your benefit of a Statin is 1 in 83 for

saving your life

right and 1 in 39 and preventing a

further heart attack

now a lot of people find that quite

underwhelming

another way of looking at the statistics

Joe and this is important for

populations

looking at those trials and when I when

I what I'm about to tell you when I talk

at conferences to doctors and general

practitioners and there's like a gasp

from the audience right when I tell them

this

and this is published in the bmj so in

the randomized trials you look at an

average

how much if I ask you that question

right you've had a heart attack let's

say for example and statins are one of

the most prescribed drugs are the you

know miracle cure whatever the one of

the most potent

um beneficial drugs in the history of

Medicine

if you take those uh if you take a

Statin for five years having had a heart

attack in that five-year period how much

would you think or hope it would add to

your life expectancy you've literally

survived a heart attack right and now

you've been given this pill which your

doctor is telling you this is you must

never stop this is going to save your

life how much would you hope it would

add to your life expectancy over a

five-year period over that period you

know we can increment 25 30 yeah okay so

a few years I've had a few years

actually yeah

you want the answer yes just over four

days

four days four days

maybe those are great days though well

no fair enough absolutely and you know

but but you know this is so and the

reason I'm mentioning that is when you

look back over the last few decades and

people talk about what has driven down

death rates from heart disease there's

this assumption it's been the mass

prescription of statins millions of

people taking statins but the evidence

suggests there's a separate analysis

done they looked in European countries

high risk and low-risk people of heart

disease over 12 years was there a

difference in was there a reduction in

heart disease death rates because of

statins and the answer was no

and that doesn't mean that the data is

fraudulent it's been misrepresented but

if you accept hc4 at a four day increase

right but these are in people who didn't

get side effects who were adherent to

statins and real world data tells us Joe

even people have had heart attacks maybe

50 of them will stop taking it just

within a few years mainly because of

side effects you can understand why that

hasn't had an impact on the population

but think about that this is one of the

most powerful

lucrative drugs in the history of

medicine and this is how

marginal

that's people out here how marginal the

benefits are now once this information

has been out there and it's been

published and you've had these talks and

people are aware of this what has been

the reaction and has there been any

change in how it's prescribed

so I then so after this publication the

bmj initially um and then I I you know I

had to

um get another job right so I lost that

job in that in that hospital I then

ended up working for free briefly in

another NHS Hospital Cardiology

Department that I work for free

doing one day a week

um because I had another role with

health policy which I'll come on to uh

you know that they were paying me some

money and I didn't want to stop seeing

patients so I was working for free in

one hospital for a year in a Cardiology

Department

um I uh in sort of March 2014.

the uh I got a phone call

in fact an email initially from the

editor of the British medical journal

and she said Aseem

um you know let's come let's have a

meeting I think I went to meet her and

she said uh there is a man called

Professor sir Rory Collins Professor

Rory Collins is probably considered in

the world the lead Statin researcher

it's Oxford University he got his

Knighthood from the queen because of his

work on steins

he has said that you need to retract

Abramson and malhotra's papers

because there is a significant error on

the side effect issue and this is going

to cause harm people are going to stop

their statins

and she said straight away no I'm not

going to retract it but we're very happy

if you would like to publish a you know

send a critique and we'll publish it but

for some reason he decided he didn't

want to do that so this back and forth

was going on and then out of the blue he

decides whether it was him or somebody

else to go to the Guardian newspaper and

I get a phone call

from the guardian and the BBC which

again was Headline News

that what Abramson

had done it became a new story front

page of the Guardian was so damaging in

terms of their error on the Statin side

effects issue that people will die

essentially this is uh almost as bad as

um they were trying to make parallels

with Andrew Wakefield and the whole

measlemonts rubella issue that happened

many many years ago that was the

scientist that lost his license because

he linked the MMR vaccine to autism

right so they were trying to create that

kind of frenzy and I'm like well this is

okay so I went on BBC and I stood my

ground and and and that I think put the

bmj under pressure

and then the next thing that happens is

I remember I was with my cousin in New

York I'll never forget this and I get an

email a press release from the bmj

which I knew was gonna you know and this

is to be honest it's it's an attack on

one's credibility

but the bmj then decided they were going

to send our articles for an independent

review uh whether or not they should be

retracted and I know Joe just to put

things in context here that's

potentially career destroying in the

sense that if my article got retracted

it got so much publicity

and and I genuinely believe what I said

was correct but it gets retracted then

your credibility is undermined pretty

much forever and your careers you know

it would be career destroying for me I'm

at the beginning of my career

so I was on trial essentially for two

months if you like and uh you know that

was it was tough it was very very tough

um there was a panel they convened they

asked me to you know send in responses

and then whatever else I didn't know

what was going to happen and then I

think it was August 2014 I remember it

broke the news and it was um you know I

got an email and basically uh the panel

had come back 6-0 unanimous in our favor

wow there was no call for attraction

because John Abramson went through a lot

during that period as well I know you

interviewed him yes and uh and we talked

and whatever else when that happened Joe

there were two things I could have done

one was wow this is like too much I

don't think I can handle this I'm just

gonna you know I'm gonna hide away and

just keep a low profile but I thought no

you know what this is about ethical

evidence-based Medical Practice there

were some corrections that needed to be

done some caveats that they added in to

into the papers around the side effects

issue so I carried on this campaign I

carried on publishing other journals

kept talking about transparent

communication ethical evidence-based

medicine Statin of a prescription there

are other things we can be doing in

terms of Lifestyle right which are going

to be more powerful you know whether

it's low carb Mediterranean diet

exercise so why are we not focusing our

attention there rather than just giving

people all these pills that they think

is going to protect them from heart

attacks and in most cases it doesn't

and in that journey and this went on for

a few years

this is where things got uh really

interesting so so there was to answer

your question yes there was a lot of

backlash it was tough there was a bit

smearing going on

um but I realized then you know as a

public health Advocate that uh

you've got to have a thick skin

and grow a rhinoceroside and those those

are the words from a man called Simon

Chapman Simon Chapman is a professor of

psychology in Australia he was

considered the lead campaigner in making

sure there was Tobacco Control in

Australia and he wrote a paper talking

about his 38-year career in public

health advocacy and gave 10 lessons on

one of those lessons is this

as soon as your work threatens an

industry or an ideological cabal you

will be attacked sometimes unrelentingly

and viciously so grow a rhinoceros hide

and I thought you know what I'm up for

it I'm up for it and so many more people

came out of the woodwork to support me

other doctors said you're right you know

and I I thought this is about truth and

transparency and about ethical medicine

and highlighting all the corruption and

the conflicts of interest one of the

things that Professor Collins it hadn't

been made apparent is his Department had

taken over 200 million pounds at Oxford

for doing research into statins from the

drug industry and they also kept the

data commercially confidential so most

of the Publications and guidelines that

are coming on statins were coming from

emanating from that department where no

one had been able to independently

verify the data and he is quoted in the

guardian saying only problematic side

effects and statins affect one in ten

thousand people

so I thought this is something this

doesn't this doesn't add up I think

these are biases conflicts of interest

I'm not saying that he was deliberately

malicious but I think there's a huge you

know conflict of interest there that is

clouding his judgment plus he's not a

clinician he doesn't see patients so

there's all of those things that I think

limit his ability to really look at the

evidence properly