Heart disease is the primary cause of death – and the most common cause of premature death – in the Western world. To reduce their risk, millions of people take statins, which lower ‘bad cholesterol’ (LDL-C). This is the accepted science.
Consequently, the latest book by the NHS-trained consultant cardiologist and researcher Dr Aseem Malhotra – A Statin-Free Life: A revolutionary life plan for tackling heart disease – without the use of statins – is bound to raise blood pressure in certain medical quarters.
In it, he examines the claims for statins, including whether lowering cholesterol really is the key to preventing heart disease.
Most astonishingly, but always citing data, he claims there is no convincing evidence that statins have lowered death rates from heart disease on a population level. Furthermore, that there is no consistent correlation between lowering LDL cholesterol and a reduction in heart attacks.
"It’s a useless biomarker in terms of predicting someone’s risk of heart disease and therefore we shouldn’t obsess about lowering it," he says. Instead, he believes the best predictor of the risk of heart disease is reached by measuring the ratio of total cholesterol to HDL, or ‘good’ cholesterol.
Such views flatly contradict the established view and the advice given by charities such as the British Heart Foundation, which point to major studies such as an analysis published in The Lancet in 2019 where scientists from Oxford and Sydney universities analysed data from 28 randomised controlled trials involving 186,854 patients. It found for every mmol/L reduction in LDL cholesterol, statins reduced the risk of a heart attack by 25 per cent and a stroke by 21 per cent.
When this is put to him, Dr Malhotra says it doesn’t correspond to ‘the totality of evidence’. Last year, he and two other cardiologists undertook an independent analysis to determine whether this statement withstood scrutiny. "We published it in BMJ Evidence-Based Medicine – systematically reviewed, peer reviewed – and we found there is no clear correlation with LDL lowering and reduction in heart attacks and strokes."
It feels like a war – with bitter accusations of misinformation and ‘fake news’ flying on both sides.
The BHF has said claims such as Dr Malhotra’s lead people to quit statins early – causing "a 26 per cent greater risk of a heart attack and an 18 per cent increase in the risk of cardiovascular mortality".
Dr Malhotra rejects this, and says, "The most important message is let’s have that transparent, honest communication with patients – explain to them the absolute benefits, respect their decision, give them alternatives."
He says statins are vastly over-prescribed. He believes debilitating side effects are common, mainly muscle pain and fatigue. Dr Malhotra, meanwhile, argues that patients in clinical trials on statins are often a ‘selected group’ – chosen because they do "not suffer side-effects from the drugs".
The son of two GPs, from the age of 11 he knew he wanted to be a heart specialist – fittingly, a desire inspired by love. His older brother, Amit, was born with Down’s syndrome. Aged 13, he developed myocarditis after a stomach bug and died in days. Dr Malhotra clearly feels his duty is to his patients – to ‘reduce suffering’. He’s forthright, and long been unafraid of ruffling feathers.
He says there is a place for statins – they improve outcomes in those with heart disease. But, he adds, "most people being prescribed statins in[the UK] are probably in the lower risk category – they’ve not had a heart attack or stroke already". This, he says, equates to roughly "a 1 per cent benefit" – a one in a hundred chance of preventing a non-fatal heart attack or stroke – "over five years of taking the drug".
A patient may still decide to take a statin, based on their individual risk factors, perhaps "a family history of heart disease", but his mission is "informed consent for patients". Too often, he says, there’s little discussion.
A Statin-Free Life contextualises his arguments. For example, he notes that cholesterol – a fatty substance made in the liver and present in all our cells – has important functions, and that LDL cholesterol plays a crucial protective role in our immune system. This could explain its presence at the site of coronary plaques (fatty deposits). Rather than a perpetrator, it’s likelier part of the rescue party, he says. "When there’s damage to the cells, because of stress, or poor diet or inflammation, the LDL responds as part of the immune system to heal or repair that."
We now know that heart disease is linked to two biological processes, he says, "insulin resistance and chronic inflammation". Insulin resistance is when cells don’t easily absorb glucose from your blood – from sugar and high GI foods – so it’s chronically raised. "Insulin itself directly damages the inner lining of the heart arteries," he says.
Simultaneously, "if the damage and repair mechanisms in the body are overridden – if there’s more damage than repair – then within the heart arteries you can develop these deposits that are full of cholesterol, actually a response to the injury – but also inflammatory immune cells."
How do we combat it? By making lifestyle changes, he says, you can "theoretically, stabilise, prevent, reduce the risk of heart attack, the risk of heart disease and, potentially, reverse heart disease".
Besides not smoking, there are four main factors to address. One – "poor diet, full of ultra-processed foods – junk foods, packaged foods high in starch, sugar, unhealthy oils. Going back to more traditional ways of eating is a very powerful step in preventing or managing heart disease."
The foods we should eat? "A combination of oily fish, nuts, whole fruit and vegetables, extra virgin olive oil – and whatever else as long as you’re minimising the sugar and low-quality carbohydrate, the breads and the pastas."
Exercise is important. "Exercise itself reduces insulin resistance. It keeps your cells more sensitive to insulin and therefore means there’s less insulin required to maintain your blood glucose in normal range, and therefore less damage to the cells of the inner lining of the heart arteries."
No need for anything fancy. "It’s really moderate activity – 30 minutes of brisk walking every day, for example."
In the world’s ‘blue zones’ – areas of notable longevity and almost no heart disease – "they weren’t pounding in the gym, running marathons. They were just moving all the time, not being sedentary." Nor, he adds, were they taking statins.
The third aspect, "often neglected", is stress. Part of this, he says, is that we’re not prioritising our relationships enough. "We know that external stress, chronic stress, in itself does increase chronic inflammation – so part of the immune system essentially attacks the body and the lining of the heart arteries." Also, chronic stress is associated with increased fibrin, a protein involved in clotting, in the blood.
Consequently, "meditation, yoga or something that reduces your stress levels will have a big impact". He cites an Indian study which found that 40 minutes of daily mediation had the strongest impact on heart disease reversal, "more than diet, more than exercise".
Number four is sleep. "Poor sleep exacerbates stress, makes you likelier to eat junk and gives your body’s repair mechanisms inadequate time to kick in."
Ultimately, whether you choose to take statins or not, Dr Malhotra says, "please, please, please do not neglect the lifestyle aspect, because 80 per cent of heart disease is environmental and lifestyle related".
He hopes that people will read his book, consult their open-minded medical experts and make informed decisions.