Making sense of all of the guidelines is not easy. All of the guidelines stress the
importance of shared decision-making with a health care provider before embarking
on long-term use of a statin drug. Since studies of the epidemiology of cardiovascular
disease indicate that having a total cholesterol below 150 mg/dl and an
LDL-C below 100 mg/dl, or better yet an LDL-C below 70 mg/dl is highly protective
against most CVDs, attaining these targets is an effective way to reduce CVD
risk. And if they can be reached through lifestyle modification, without statins or
other drugs and their attendant risk of side effects, these targets are a worthy goal.

The most important action to prevent CVD should always be to adopt a healthy lifestyle
with normal weight and blood pressure, a healthy diet and plentiful physical
activity. As a Viewpoint in the JAMA noted, “… the ACC/AHA risk calculation
leads to treatment as men become older even if they have no risk factors other than
their unmodifiable age and sex. To many, it sounds absurd that there is no such thing
as healthy aging and that everyone eventually will need some medication.”

But if a healthy lifestyle does not suffice to reach a LDL-C below 100 mg/dl, the
available evidence demonstrates benefit from statin use, including for those who do
not have markedly high blood cholesterol. A recent a meta-regression analysis
in JAMA suggests that the lower the LDL-C, regardless of the therapy used to lower
it, the lower the relative risk of major vascular events. If statins are needed to
obtain the optimal blood lipid pattern associated with the lowest risk of CVD, the
preponderance of evidence indicates that they should be used, even in those without
overt CVD. Statins cause few adverse effects, lower rates of CVD by about 30%,
and lower all-cause mortality by 10% to 15%.

In spite of uncertainties about their use in individuals younger than 40 and older
than 75, I recommend basing the decision to use statins mainly on the presence of
risk factors, i.e., the presence of hypertension, obesity, physical inactivity, and especially
on blood lipid levels. The risk calculator is certainly one factor to consider,
but I favor aiming for the blood lipid level targets that are known to be associated
with decreased CVD risk, i.e., an LDL-C of 70 mg/dl or lower, rather than on a
the 10-year CVD risk formula. The University of California, Berkeley Wellness Letter,
is also on record supporting blood lipid level targets rather than the projected
10-year risk of CVD events. (Full disclosure: I serve on the editorial board of the
University of California, Berkeley Wellness Letter.)

This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel