Should I start statin therapy?
Adam Bataineh
Medical Director at Numenor
A new study published in the New England Journal of Medicine has convinced me to start taking microplastics way more seriously (Study title: Microplastics and Nanoplastics in Atheromas and Cardiovascular Events).
The study was a first of its kind to analyze plaque samples obtained from the carotid arteries of 304 participants for the presence of microplastics and nanoplastics. They followed the participants for 34 months and compared those with microplastics and nanoplastics in their samples to those without. The results were quite alarming.
Here are my main takeaways:
1- Polyethylene— a common type of plastic—was detected in the carotid artery plaque of nearly 58.4% of the patients, with some also showing traces of polyvinyl chloride.
2- The presence of microplastics and nanoplastics in arterial plaque was associated with a significant increase in the risk of severe cardiovascular events such as heart attacks, stroke and death from any cause. These people were over 4 times more likely to have a cardiovascular event happen compared to those without plastic particles in their arteries.
3- This is one of the best designed studies I have seen on this topic. It clearly demonstrates that microplastics accumulate in our bodies and more importantly, increase risk of severe health issues and death.
4- The main behavior changes I now implement personally and recommend to avoid microplastics:
• Stop using plastic containers or bottles for food or fluids (especially if heated)
• Limit single use plastics in general unless necessary (I always remove plastic coffee cup lids for example).
• Don’t use tea bags (replace with loose leaf tea)
Let me know if you have any questions about this topic or other topics you’d like me to cover.
Visit www.numenor.health for more information about our approach to health and longevity.
Adam Bataineh MD
Medical Director, Numenor
Here's what we know about cholesterol
1 - High levels of cholesterol have a causative relationship with heart disease1
2 - Lowering low-density lipoprotein (LDL) cholesterol can significantly reduce the risk of atherosclerosis and heart attacks2
It therefore logically follows that making sure your cholesterol levels are within a healthy range is important for long term health. While cholesterol is not the only factor here, it is an important one for the simple reason that it is an easily and safely modifiable risk factor for heart disease.
In fact, we now know that atherosclerosis regression is possible. A recent study demonstrated complete regression in early atherosclerosis in people with certain interventions and characteristics, one of them being lowering LDL cholesterol3.
The study also showed that exposure to high LDL-C (and elevated blood pressure) early in life has a more marked effect on atherosclerosis progression than later exposure. This makes it clear that correcting these factors as early as possible is crucial for optimal prevention.
There are two ways of lowering cholesterol levels: lifestyle changes and pharmacological interventions.
The question is, when should you consider pharmacological intervention?
When are statins indicated?
Classically, risk calculators like the QRISK3 tool are used to estimate 10-year risk of cardiovascular disease. A risk of 10% or more is usually considered significant and a marker for starting statins. Based on what I described above, I believe waiting until the risk of heart disease reaches this level is way too late.
Lifestyle modifications such as improving nutrition, particularly through a Mediterranean diet, can lower cholesterol levels by 20 to 30%4. This diet emphasizes fruits, vegetables, whole grains, and healthy fats.
Regular exercise can have modest but significant effects on cholesterol levels, mainly by improving HDL cholesterol levels with more intense activity required to show reductions in LDL5.
If you aim to lower your cholesterol levels by more than 30-40%, it may be difficult to achieve this through dietary changes alone. Another issue we come across often is people who already adopt a healthy diet and ideal weight but have a high cholesterol level. In these cases, dietary changes may not have significant effects. This is because about 50% of high cholesterol is attributed to genetics6. Age-related dysfunction likely makes this percentage even higher.
Another issue is practicality and adherence. Calorie restriction to 1,780 kcal/day, for example, seems to be an effective way to control cholesterol levels7 but realistically, this is unlikely to be a successful long term strategy for most people.
Statins are generally the first line of treatment due to their proven effectiveness and safety. They can lower LDL cholesterol by 20 to 50%, significantly reducing the risk of heart disease. There are however, other available options which are not covered in this article.
In a nutshell, here’s when you might consider statin therapy:
- If your cholesterol levels need to be reduced by more than 30%
- If adhering to a healthy diet is challenging
Evaluating the risks and benefits of statin therapy
Risks
No medical intervention is without risks, and statins are no exception. Here is a list of some of the potential risks of statins:
Muscle aches
How common is it?
Incidence can vary between 0.3 to 33% depending on the study.
How reliable is this relationship?
Studies have shown that up to 90% of these side effects are in fact unrelated to statin therapy.
How serious is this?
The vast majority of people experiencing this side effect will go back to normal upon stopping the statin.
Rhabdomyolysis
In less than 0.1% of patients rhabdomyolysis may occur. This is a serious condition that causes muscles to break down and may have serious consequences.
Hyperglycemia and diabetes
In a large analysis of patients on statins for 4 years, there was one extra case of diabetes recorded over what was expected. This depends markedly on individual risk factors (patients who are already at increased risk of developing diabetes) (Sattar N, et al. Lancet 2010; 375: 735–42).
Other side effects have also been reported in association with statins. These are listed in the summary of product characteristics and patient information leaflet of each statin.
Do statins cause dementia?
A 2022 systematic review and meta-analysis on statin therapy and dementia risk showed no increased risk of dementia8. Another study published in 2021 of almost 20,000 adults over 65 showed that those on statin therapy did not have an increased risk of either dementia or even mild cognitive impairment in domains including global cognition, memory, language, executive function or psychomotor speed.
Is long term extreme lowering of cholesterol safe?
Extremely low lifelong LDL cholesterol levels (less than 1.4 mmol/l) have been show to be safe and associated with extremely low cardiovascular event rates9.
Benefits
Reduction in risk of heart disease
A large meta-analysis of randomized trial data showed that if patients with a high cardiovascular risk take statins for at least 5 years, about 450 heart attacks and strokes per 10,000 treated patients can be prevented10.
Which statin should I use?
There are a handful of statins available. The choice of statin depends on personal factors and the desired effect. In general, Atorvastatin or Rosuvastatin are the preferred first choice for primary prevention. Below is a figure showing the relative effect of different kinds of statins on LDL cholesterol levels11:
2018 Guidelines for the management of dyslipidemia. July 2019 The Korean Journal of Internal Medicine
In certain conditions, other statins may be more appropriate. In cases of high risk of new diabetes for example, Pitavastatin may be more appropriate. In the elderly, Pravastatin can be a preferred option12.
Deciding to start statin therapy should always be based on a thorough discussion with your healthcare provider, considering all risks and benefits. This decision is not just about managing cholesterol but also enhancing the quality and longevity of life. With the right approach, statins can be a valuable part of cardiovascular disease prevention strategies, especially when lifestyle changes alone are insufficient.
Adam Bataineh MD
Medical Director, Numenor
References:
1 https://pubmed.ncbi.nlm.nih.gov/32052833/
2 https://pubmed.ncbi.nlm.nih.gov/32052833/
3 https://www.jacc.org/doi/10.1016/j.jacc.2023.09.814
4 https://pubmed.ncbi.nlm.nih.gov/32615714
5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906547
6 https://pubmed.ncbi.nlm.nih.gov/29459468/
7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC404101/
8 https://pubmed.ncbi.nlm.nih.gov/34871380/
9 https://pubmed.ncbi.nlm.nih.gov/16554528/
10 https://pubmed.ncbi.nlm.nih.gov/22607822/
11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610190/
12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10528630/
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