I tweeted a link to a study today about the use of Statin cholesterol drugs in essentially any patient over the age of 50, and how routine use in these patients significantly lowered their risk for a significant cardiovascular event (heart attack or stroke). Now before you just dismiss this as another example of how big pharma is trying to take over the world, let me tell you why you need to pay attention to this study.
First of all it’s big…like 175,000 people big. In the world of clinical studies, that’s a very impressive number. The more patients take part in a clinical trial the more powerful it is in general. This study took 175K people and showed that even in patients with a very LOW risk for heart disease, statin drugs improved their risk of events significantly. Is this surprising? Not at all!
Several years ago the so called JUPITER trial looked at the ability of statin drugs to lower what is called highly sensitive CRP (hsCRP). Studies have shown a very nice correlation between hsCRP levels and short term risk of heart attack. Levels below 1 are good, between 2-3 are moderate risk, and between 4-10 are high risk for badness. This trial took 18,000 patients with low LDL (bad cholesterol) and no cardiac risk factors and put them on statins vs. placebo. The results were so beneficial for the statin group that the study was called off early to allow the placebo group the chance to take a statin. The marker used to track benefit was a consistent drop in hsCRP in the statin group.
So what does that mean? CRP is what we call a marker of inflammation. A regular CRP measures levels of inflammation throughout the entire body, while hsCRP was developed specifically to look at inflammation in the cardiovascular system. So if we can lower the hsCRP it means that we are lowering the inflammation in the cardiovascular system (easiest way to look at it). In turn, if statins lower hsCRP, then they must have anti-inflammatory activity right?
That is absolutely right. It has always been known that statin drugs have a kind of two tiered mechanism of action. The significant improvement we see in cardiovascular risk seen in patient’s taking statins is too great to be coming only from a simple drop in the patient’s cholesterol. Statins go into the inflamed walls of diseased arteries and block inflammation. They are what we call “Plaque Stabilizers.” Heart attacks and strokes occur when an artery wall is inflamed and swollen with inflammatory markers and cholesterol. A plaque can be “stable” when it is relatively dense, or “unstable” when it is fluffy and chock full of inflammation and fat. One little irritation in the cap of an unstable plaque leads to a lighting fast inflammatory response and acute blockage of the artery with a clot. Anything downstream does not get oxygen; if its heart tissue you get a heart attack, if it’s brain you get a stroke. So statins without doubt lower your risk of heart attack by lowering your cholesterol, as well as lowering the inflammation in your arterial walls. This is essentially fact.
Another action statins have on the inflammatory cascade of heart disease is that they counteract the known inflammatory effects of Omega-6 fatty acids. In our world where the fat pendulum has swung almost completely to the Omega-6 (over Omega-3) side of the aisle, there is no surprise that statins help so much. Again, this is essentially fact.
The mistake that was made many years ago was in believing that statins purely lowered heart disease risk by lowering blood cholesterol levels. Linear thinking led to the belief that lowering dietary cholesterol and fat MUST in turn lower heart disease risk as well. Good idea, just not the right idea! Statins REALLY work through their anti-inflammatory properties to lower cardiovascular risk, but we didn’t figure that out till later! Easy mistake to make, but now that we know the rest of the story, we need to go back and correct our thinking. Unfortunately that is proving more difficult than many of us would like.
One other thing to discuss is side effects of these medicines. I am completely amazed at the generalized fear and misrepresentation of the side effects of statin drugs. They have clear and known potential risks, particularly concerning the liver and with generalized muscle weakness. That being said, I can say in my clinical experience these drugs are generally very well tolerated and safe. I have been prescribing statins for near 11 years in both training and private practice, and I know of one definitive case of rhabodomyolosis (life threatening muscle breakdown) and only a handful of cases involving significant (but fully reversible) liver inflammation from the drugs. Are statins for everyone? No. Are they the most dangerous drugs in the world that should be pulled off the market? Absolutely not. They are safe, and they work.
So, what am I saying? Does everyone need to be on a statin? Well, if we don’t change our dietary ways as a society the answer may be yes! In my humble opinion there is a better way of course! Say for example we significantly curtail wheat in our diet, as well as any other similar proteins that can cause generalized inflammation in our bodies. This should in theory lower our overall CRP levels, and likely our hsCRP levels as well. In addition, what if we concentrated on changing the fatty acid profile of our foods to shift the Omega-3:Omega-6 ratio back to the side of Omega-3s. This would be like turning back the hands of time in our food supply to a time when corn, soy, and wheat did not dominate our agriculture. We know (fact) that Omega-3 fatty acids are not atherogenic so we would easily lower our cardiovascular risks as a whole. With these two actions as a society we would accomplish the same thing as giving everyone a statin. Amazing huh?
The problem is that these changes would be very hard to bring around. It is easy for us to sit on our Paleo high-horses and state the obvious, but it will be a real battle. A fundamental change in the way we raise our protein in America and around the world will be a daunting task. Finding ways to affordably feed the world’s population without a dependence on extremely cheap wheat based products will take years of work. It is not easy, but I feel it must be done.
I hope this helps you think twice next time you see a headline about the benefits of a drug. Before you spout off some diatribe about the evils of big pharma, look closely at what it’s all about. Are statins overused?…according to this study they should be used more! And, we likely WILL use them more. That being said Statins work, they are safe, and most interestingly they teach us a great deal about inflammation, heart disease, and why our beloved Paleo lifestyle works.
I hope this all made sense to everyone. If you have any questions leave a comment or feel free to tweet me at @PaleoHikerMD.
In the end…it’s ALL about inflammation!