Between 2002 & 2013 statin use in the US nearly doubled, cholesterol levels are falling, yet cardiovascular deaths appear to be on the rise; statin usage may lead to unhealthy behaviours that may actually increase risks

Hit or miss: the new cholesterol targets. Robert DuBroff, Aseem Malhotra, Michel de Lorgeril. BMJ Evidece-Based Medicine, Aug 2020. http://dx.doi.org/10.1136/bmjebm-2020-111413

Abstract: Drug treatment to reduce cholesterol to new target levels is now recommended in four moderate- to high-risk patient populations: patients who have already sustained a cardiovascular event, adult diabetic patients, individuals with low density lipoprotein cholesterol levels ≥190 mg/dL and individuals with an estimated 10-year cardiovascular risk ≥7.5%. Achieving these cholesterol target levels did not confer any additional benefit in a systematic review of 35 randomised controlled trials. Recommending cholesterol lowering treatment based on estimated cardiovascular risk fails to identify many high-risk patients and may lead to unnecessary treatment of low-risk individuals. The negative results of numerous cholesterol lowering randomised controlled trials call into question the validity of using low density lipoprotein cholesterol as a surrogate target for the prevention of cardiovascular disease.

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What to do now

Cardiovascular disease continues to be the leading cause of death worldwide. Between 2002 and 2013 statin use in the US nearly doubled, cholesterol levels are falling, yet cardiovascular deaths appear to be on the rise.30 31 In Sweden, recent widespread and increasing utilisation of statins did not correlate with any significant reduction in acute myocardial infarction or mortality, while in Belgium a very modest reduction in cardiovascular events was reported between 1999 and 2005, but primarily in elderly individuals not taking statins.32 33 These population studies suggest that, despite the widespread use of statins, there has been no accompanying decline in the risk of cardiovascular events or cardiovascular mortality. In fact, there is some evidence that statin usage may lead to unhealthy behaviours that may actually increase the risk of cardiovascular disease.34 35 The evidence presented in this analysis adds to the chorus that challenges our current approach to cardiovascular disease prevention through targeted reductions of LDL-C. Given the lack of clarity on how best to prevent cardiovascular disease, we encourage informed decision-making. Ideally, this includes a discussion of absolute risk reduction and/or number needed to treat at an individual patient level in addition to reviewing the potential benefits and harms of any intervention.