A Title shift from: (title was) Are fats in the diet responsible for heart disease? to 'should one treat high values'

hari kumar

Honestly, I debated whether to respond at all to this shift in discussion emphasis. It shifts from talking about diet - to more active treatments and preventions with statins. In the end a short foray seemed sensible, to counter over-simplifications. 

As an aside, the discussion also obviously does have some important political aspects, going beyond the large obvious one - namely of profits for big pharma. 

I am certainly not a cardiologist, nor a cholesterol biologist nor a nutritionist. However maybe a brief note about the potential non-treatment of high cholesterols with statins, might be worthwhile. It is 'brief' -  as this literature is enormous and beyond my time, energy or expertise. This focuses only on heart consequences, not the emerging ones of cancers or cognition. Having said that:

1) No drug or therapy is without complications or side effects, as everyone here would likely agree. [I am not even mentioning costs here]. That is why large data sets that amalgamate  in meta-analysis (MA) -  at best the numbers from randomized controlled trials. But if that is not possible (RC trials are both difficult and expensive and at the end of the day, almost never answer all possible and relevant questions) - MAs should amalgamate large prospective studies. In this case, my literature read is that such MAs do suggest benefit. The most recent I know of is in the brackets here (Association Between Baseline LDL-C Level and Total and Cardiovascular Mortality After LDL-C Lowering A Systematic Review and Meta-analysis'; Eliano P. Navarese,MD, PhD; Jennifer G. Robinson, MD, MPH; Mariusz Kowalewski, MD; Michalina Kołodziejczak, MD; Felicita Andreotti, MD; Kevin Bliden, MD; Udaya Tantry, PhD; Jacek Kubica, MD, PhD; Paolo Raggi, MD; Paul A. Gurbel, MD; JAMA. 2018;319(15):1566-1579. doi:10.1001/jama.2018.2525).

Since no study is perfect, naturally qualifications remain. These can be seen best in the three editorials on this paper - itself unusual, thus reflecting the intensity of debate and uncertainties in the field. The title of one of these editorials displays this ( 'Statins for Primary Prevention. The Debate Is Intense, but the Data Are Weak'; Rita F. Redberg, MD, MSc; Mitchell H. Katz, MD; JAMA November 15, 2016 Volume 316, Number 19 1979). 

These editorials do not reject the authors' conclusions, but raise sound queries that in my view, revolve around risk-stratification. In other words - who is at high risk and who is not and are these balanced in various analyses? One of these editorials explicitly discusses making decisions to treat with the proposed patient using 'shared decision-making' methods to explicitly lay out risks and benefits.   

2) Since the name has come up: A response to Ravnskov is also helpful in assessing how to weigh the total evidence. This reply points out in response to Ravnskov, some important methodological issues of relevance - including length of follow-up needed, before making conclusions (Response by Abdullah et al to Letters Regarding Article, “Long-Term Association of Low-Density Lipoprotein Cholesterol With Cardiovascular Mortality in Individuals at Low 10-Year Risk of Atherosclerotic Cardiovascular Disease: Results From the Cooper Center Longitudinal Study” Circulation. 2019;139:2192–2193).  

Sorry this has been rather long. Even so it remains inadequate I fear, and it is rather general. I will also say - for whatever it is worth - that I have been on first-generation statins for about 20 years following some cardiac events and family history.  

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