If there’s one medication that seems to spark more debate than almost any other, it’s statins.
Spend five minutes online, and you’ll find people claiming they’re miracle drugs that everyone should take. Spend another five minutes and you’ll find people convinced they’re dangerous medications that should be avoided at all costs.
Neither extreme reflects how I think about cardiovascular prevention.
One of the most common questions I hear in my office is, “My cholesterol is high. Do I need a statin?”
I actually think that’s the wrong question.
The better question is:
“What is the best strategy to reduce this person’s lifetime risk of cardiovascular disease?”
Sometimes that strategy includes a statin.
Sometimes it doesn’t.
That’s where personalized medicine begins.
We’ve Reduced Cardiovascular Prevention to a Cholesterol Problem
One of the biggest misconceptions in medicine is that elevated cholesterol automatically means you need medication.
It doesn’t.
Cholesterol is a risk factor—not a disease. It doesn’t tell the entire story because cardiovascular disease is far more complex than any single biomarker..
Two people can have the exact same LDL cholesterol and have dramatically different risks of experiencing a heart attack over the next decade. One may have significant coronary plaque, insulin resistance, hypertension, and a strong family history of early heart disease. The other may be metabolically healthy, physically fit, have a coronary artery calcium score of zero, and carry very little overall cardiovascular risk.
Treating those two patients the same simply because they share the same LDL cholesterol doesn’t make sense.
For years, many treatment decisions have relied primarily on LDL cholesterol, age, and population-based risk calculators. Those tools are helpful, but they’re designed to estimate risk across large populations—not the individual sitting in front of me.
They don’t know whether you already have coronary plaque. They don’t know your ApoB, Lipoprotein(a), inflammatory burden, endothelial function, body composition, cardiorespiratory fitness, metabolic health, or the quality of your sleep. They don’t know how much visceral fat you carry or whether your blood pressure has been quietly climbing for years.
Most importantly, they don’t tell me why this particular patient is at risk.
That’s the question I want answered before recommending a medication someone may take for decades.
Treat the Patient, Not the Cholesterol
I think this is where statins are often misunderstood.
The goal of preventive cardiology isn’t to prescribe statins. It’s to prevent heart attacks, strokes, and premature cardiovascular disease. Sometimes a statin is one way to accomplish that. Other times, the greatest opportunity lies elsewhere.
When someone already has established cardiovascular disease—whether they’ve experienced a heart attack or stroke, undergone coronary stenting or bypass surgery, or have documented plaque—the conversation changes. In these patients, the data to support lowering LDL cholesterol to evidence-based goals is much stronger for reducing the risk of another cardiovascular event. How we achieve those goals is individualized and may include a statin, ezetimibe, bempedoic acid, a PCSK9 inhibitor, or a combination of therapies, including nonpharmaceutical ones. The goal isn’t prescribing a particular medication—it’s reducing cardiovascular risk.
Primary prevention is different.
Preventing a first cardiovascular event requires a much more nuanced discussion because the potential benefit varies tremendously from one person to the next. That’s where personalized risk assessment becomes essential.
Like every medication, statins also have potential downsides. Some patients experience muscle symptoms, and studies have demonstrated a modest increase in the risk of developing diabetes among susceptible individuals. For someone at high cardiovascular risk, those trade-offs are often well worth it. For someone whose overall risk is quite low, the equation may look very different.
Medicine isn’t simply about whether a medication works.
It’s about whether it’s the right medication for the right patient at the right time.
I’m More Interested in Treating Physiology Than Numbers
Medicine has become remarkably good at lowering numbers. We lower LDL cholesterol, blood pressure, blood sugar, and inflammatory markers—and those things absolutely matter.
But numbers are only part of the story.
I’m more interested in understanding why those numbers are abnormal.
Why is this person’s ApoB elevated? Why are they insulin resistant? Why are they accumulating visceral fat? Why are they developing plaque while someone else with similar cholesterol isn’t?
The answers to those questions determine where the greatest opportunity lies. Sometimes it’s improving insulin sensitivity. Other times it’s restoring endothelial function, reducing visceral fat, treating hypertension, improving cardiorespiratory fitness, or addressing vascular inflammation.
The intervention should match the physiology.
That’s what personalized prevention looks like.
Learn More
Two topics come up in nearly every discussion about statins, and each deserves a much deeper conversation than can fit in this article.
- Statins and Brain Health: What does the evidence actually say about memory, cognition, and dementia?
- Heart Disease in Women: How do menopause, pregnancy, and sex-specific differences influence cardiovascular prevention?
I’ll explore both of these topics in future articles.
This article is for educational purposes only and should not be considered medical advice or a substitute for individualized medical care.