New Cholesterol Guidelines Could Significantly Reduce Statin Use

Statin cholesterol-lowering drugs are among the most prescribed medications in the United States, but the number of people taking them could soon be significantly reduced. Under previous guidelines, 45.4 million adults met the criteria to take statins, but that number would drop to 28.3 million if the updated guidelines from the American Heart Association are adopted.^One

This is good news, given that statins do not protect the heart and most people do not need them to lower their cholesterol. At the population level, it is very likely that public health would improve if fewer people were prescribed statins, because statins are harmful in the long run.

Previous statin guidelines increased usage by 149%.

The last cardiovascular disease risk calculator was released in 2013. Known as the Pooled Cohort Equation (PCE), it primarily estimates the 10-year risk of heart attack and stroke for people ages 30 to 79, providing guidance on statin use.²

Since the publication of the 2013 statin guidelines, the number of people using statins has increased by 149%, from 37 million between 2012 and 2013 to 92 million between 2018 and 2019. Additionally, the number of annual statin prescriptions filled has increased from 461 million to 818 million between 2008 and 2019.^three Meanwhile, despite increasing statin use, heart disease has been 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 from heart disease has increased from the late 2010s to 2020.⁴

In November 2023, the American Heart Association (AHA) and the American College of Cardiology (ACC) will update their cardiovascular risk assessment guidelines, which may result in significant changes to statin treatment recommendations. Unlike the 2013 guidelines, the 2023 AHA Prediction of Cardiovascular Event Risk (PREVENT) equation provides a more comprehensive risk assessment.

One difference is that the new calculator removes race and replaces it with an individual’s ZIP code, which represents 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.⁵ Provides information about a person's average blood sugar levels over the past two to three months. According to the AHA:⁶

“The calculator estimates your risk of heart attack, stroke, and, for the first time, heart failure. The equation is gender-specific and race-independent, recognizes that race is not a biological factor, and can include an index of social determinants of health.

This is the first risk calculator to estimate cardiovascular disease risk by combining measures of cardiovascular, renal, and metabolic health. It was developed using health information from more than 6 million adults, including people from diverse racial and ethnic, socioeconomic, and geographic backgrounds.”

New guidelines show about 40% fewer people meet criteria for statins

A cross-sectional study published in JAMA Internal Medicine found that adopting the PREVENT equation into national guidelines would reduce the number of people eligible to receive statin medications by about 40 percent.⁷

This study, which analyzed data from the National Health and Nutrition Examination Survey from 2017 to March 2020, comprised a weighted sample of 3,785 U.S. adults aged 40 to 75 years without atherosclerotic cardiovascular disease (ASCVD).

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

About 4.1 million people currently taking statins no longer meet the criteria for taking the drugs under PREVENT, which means their health care providers may tell them to stop taking them.

“The previous risk equations and the PREVENT equations that we focused on in this study are really trying to give physicians and patients a kind of starting ratio to start with that might say, is it worth having the conversation about statins?” senior study author Dr. Timothy Anderson of the University of Pittsburgh Medical Center told STAT. “When you see that the risk ratio is cut in half, I think that’s something that has the potential to influence how physicians and patients talk about these drugs.”⁸

Statins Are Not the Answer for Heart Health

Even with new guidelines that reduce the number of people who can use statins, these interventions will likely do more harm than good for the vast majority of people who take them. Statin drugs have not derailed the rising trend of heart disease, but instead increased the risk of health problems associated with their use, such as diabetes.^9,10 idiot¹¹ and others, including:

• cancer¹²
• Cataract¹³
• Musculoskeletal disorders including myalgia, muscle weakness, muscle cramps, rhabdomyolysis and autoimmune muscle diseases¹⁴
• depression¹⁵

Aside from the increased health risks, the widespread myth that statins lower cholesterol and improve heart health still permeates modern medicine and promotes inappropriate use of statin drugs. The Framingham Study, which began in 1948, involved 5,209 people in Massachusetts.¹⁶ It played a major role in creating the myth that high total cholesterol is a major risk factor for heart disease.

However, the correlation only existed when cholesterol was above 300 milligrams per deciliter (mg/dl). “Very few people have total cholesterol that high,” Dr. Asim Malhotra, a consultant interventional cardiologist, explained on The Joe Rogan Experience.¹⁷

What's also not widely known about the Framingham study is that it happened in people over the age of 50 or 60. In that age group, as cholesterol dropped, mortality increased. “So the link between cholesterol and heart disease is very weak, to begin with,” Malhotra says.¹⁸

Malhotra and colleagues conducted a study to see if there was a correlation between lowering LDL cholesterol and total cholesterol and preventing heart attacks and strokes, but no clear correlation was found. “This is the strongest evidence we can get because it’s based on randomized controlled trial data,” he says.¹⁹

Statins deplete CoQ10 in the body

Your body's production of coenzyme Q10 (CoQ10) peaks around age 25 and begins to decline thereafter. By age 65, your body typically produces only half the amount it did at age 25.²⁰ Aging isn’t the only factor that can decrease CoQ10 levels. Statin drugs are also known to deplete CoQ10.

Statins work by blocking an enzyme in the liver called HMG coenzyme A reductase, which reduces cholesterol production. However, this same enzyme is also involved in the production of CoQ10, leading to its depletion. Decreased CoQ10 can often contribute to the muscle-related side effects associated with statins. It is also worth noting that LDL cholesterol, which statins aim to reduce, is the primary carrier of CoQ10 in the bloodstream.²¹

So if you take statins, be aware that they deplete your body of CoQ10 and inhibit vitamin K2 synthesis. While younger individuals can generally utilize CoQ10 supplements effectively, older adults may benefit more from the more easily absorbed form, ubiquinol.

If you are taking a statin, you may need at least 100 milligrams (mg) to 200 mg of ubiquinol or CoQ10 daily, and possibly more. It is best to talk to your doctor to determine the dose that is right for you.

Generally, healthy individuals need only 30 to 100 mg per day, while those in poor health may need 60 to 1,200 mg per day. If you lead an active lifestyle, exercise frequently, or are under significant stress, 200 to 300 mg per day may be helpful.

Gut bacteria linked to reduced risk of heart disease

To protect your heart health, it’s better to target your gut health than rely on prescription drugs. Evidence suggests that altered gut microbiomes are linked to cardiovascular disease. Researchers at the Broad Institute, Massachusetts General Hospital, and Harvard have pinpointed specific gut bacteria that affect cholesterol levels, triglycerides, blood sugar levels, and heart disease risk.^22,23

When they analyzed the bacterial genomes in stool samples, they found that a type of bacteria called O. silibacter was associated with lower cholesterol levels, lower triglycerides and glucose, and higher high-density lipoprotein (HDL) levels. The scientists also found that O. silibacter broke down cholesterol into smaller molecules that did not increase the risk of heart disease.

“The cholesterol reduction by Oscillibacter appears to be linked to genes for enzymes that break down cholesterol in the gut, which may reduce the amount of cholesterol entering the bloodstream,” they explained.²⁴ In fact, improving your gut health is essential to avoiding heart disease, because a diverse and balanced gut microbiome is essential for overall health.

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

These compounds nourish the colonic epithelial cells, strengthening their barrier. SCFAs also stimulate the production of mucus, which forms a protective barrier against harmful bacteria.

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

Optimizing your gut health is a key strategy for protecting your heart health.

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

This may lead to 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 a stronger negative response to plant-based carbohydrates due to increased endotoxin exposure.

On the other hand, many people do not know that septic shock is the leading cause of death and that endotoxemia is often the root cause. In my opinion, the number one cause of death, surpassing heart disease and cancer, is endotoxemia leading to septic shock. Because what is written on the death certificate is not necessarily the real cause of death.

For example, heart disease or heart failure can often be caused by endotoxemia, so improving mitochondrial function and maintaining a healthy gut ecosystem can help prevent heart disease.

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

The potential decline in statin prescriptions based on the AHA’s updated risk assessment tool further emphasizes the importance of personalized medicine rather than a one-size-fits-all approach. A holistic approach to heart disease prevention is needed because heart health is not isolated but deeply intertwined with overall well-being.

It is important to consider the complex interplay of gut health, mitochondrial function, and various health markers, as well as specific traditional risk factors. This change in perspective may lead to more effective and less invasive strategies for maintaining cardiovascular health and reducing heart disease risk in the long term.