I have spent much of my 35-year medical career questioning the conventional wisdom surrounding cholesterol and cardiovascular disease. I’m an internist, a lipidologist, and what I affectionately call a lipidologist in recovery. I even wrote a book challenging the widespread use of statins.
I remain skeptical of the idea that cholesterol is the principal villain in coronary artery disease. I believe inflammation, immune responses, and potentially infectious organisms deserve considerably more attention than they’ve received. I’ve long argued that lowering a laboratory number is not the same thing as improving someone’s life.
And then, this week, I became the patient. At age 64, I underwent a coronary CT angiogram. My coronary calcium score was 51. Fifteen years earlier, it had been 19. Not particularly alarming numbers.
But the angiogram told a more complicated story. I have multivessel coronary atherosclerosis, including noncalcified plaque, moderate narrowing in several branches, and what appears to be an occluded small obtuse marginal artery. No critical left main obstruction. No dramatic proximal LAD lesion. No obvious reason to panic. But unmistakable coronary disease. Suddenly, a debate I’ve participated in for decades became personal.
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Should I take a statin?
I know the literature. I’ve read the trials, examined the composite endpoints, and calculated the absolute risk reductions. I’ve questioned whether modest reductions in nonfatal myocardial infarctions justify treating millions of otherwise healthy people indefinitely. I still have those questions.
The Treating to New Targets (TNT) trial demonstrated that increasing atorvastatin from 10 to 80 mg reduced nonfatal myocardial infarctions by approximately 1.3 percentage points over five years. That’s a number needed to treat (NNT) of about 77. Coronary revascularizations were also reduced. There was no significant improvement in all-cause mortality.
Of course, TNT compared two statin doses, not statin treatment against no treatment. And its participants had clinically established coronary disease, making them different from someone whose atherosclerosis is discovered through imaging. But the coronary event reductions are real. I can criticize the cholesterol hypothesis without pretending those randomized results don’t exist.
I also looked at bempedoic acid, an oral nonstatin medication. In CLEAR Outcomes, it reduced fatal or nonfatal myocardial infarctions from approximately 4.8 percent to 3.7 percent over 3.4 years. An absolute benefit of 1.1 percentage points, or an NNT around 91. Again, meaningful. Again, not miraculous. And the trials cannot be compared directly.
The evidence for statins is more extensive. I can acknowledge that, too.
Here’s where the experience became genuinely interesting. I realized that I was experiencing the same ambivalence I have seen in my patients for decades.
I didn’t want another prescription. I didn’t want to reconsider convictions I’d spent years developing. I didn’t want to be frightened into treatment by an imaging report. And I certainly didn’t want a cardiologist reciting guidelines as though I had never heard of them.
I wanted someone to help me think. Someone willing to admit what we know, what we don’t know, and how uncertain the benefit might be for one particular person. Someone who could distinguish a reduction in nonfatal heart attacks from a reduction in mortality. Someone who wouldn’t confuse disagreement with ignorance. That is what our patients deserve.
Medicine has become increasingly uncomfortable with uncertainty. Guidelines encourage us to categorize, prescribe, and move on. A reluctant patient is too often labeled noncompliant.
But reluctance is not necessarily irrational. A patient who questions a lifelong medication may be weighing benefits and harms quite reasonably, even if their interpretation of the evidence differs from ours. And physicians can make that conversation worse by exaggerating treatment benefits.
Tell a patient a medication reduces heart attacks by 25 percent, and it sounds extraordinary. Explain that the absolute benefit in a particular trial was approximately one fewer event per hundred patients over several years, and the conversation becomes more meaningful. Neither statement is necessarily false. But only together do they allow an informed decision.
I’ve also learned something uncomfortable about myself. Intellectual skepticism can become intellectual identity. After years of publicly challenging an established medical narrative, changing one’s treatment preferences may feel like surrender. It isn’t.
Science is not a loyalty oath.
I can continue believing that the infectious and inflammatory components of atherosclerosis have been underexplored while accepting that reducing ApoB-containing lipoproteins has demonstrated clinical benefit. Both propositions can be true. A therapy doesn’t need to validate every assumption about a disease to be useful.
And perhaps the most important distinction of all: I don’t need to become convinced that statins are wonderful to decide that taking one might be reasonable for me.
Where does that leave me?
I’m leaning toward trying atorvastatin. Not because I’ve had a religious conversion to the cholesterol hypothesis. Not because my calcium score of 51 terrifies me. And not because I believe medication will guarantee me a longer life.
I’m considering it because I now have documented coronary disease, because the evidence for reducing coronary events is substantial, and because my personal balance of benefits and harms has changed. I may ultimately choose a nonstatin approach. I may start with a modest dose. I may change my mind. What matters is that I make the decision with intellectual honesty rather than ideological consistency.
And there’s a lesson here for other physicians. The next time a patient resists a statin, a blood pressure medication, a screening procedure, or another recommendation, resist the temptation to win the argument. Ask what concerns them. Show them the absolute numbers. Acknowledge the limitations of the evidence. Explain how their individual circumstances change the calculation. And recognize that a thoughtful patient may legitimately value the same outcomes differently than you do.
Sometimes the most useful thing a physician can say is, “Here’s what I would do, here’s why, and here’s what remains uncertain.”
I’ve spent decades helping patients navigate those decisions. This week, I discovered how different they feel when the prescription might be mine.
I haven’t abandoned my skepticism. I’ve simply remembered that the purpose of skepticism is to get closer to the truth, not to defend a position indefinitely. And sometimes the most honest words a physician can say are: “I might have to rethink this.”
Larry Kaskel is an internist and “lipidologist in recovery” who has been practicing medicine for more than thirty-five years. He runs a concierge practice in the Chicago area and serves on the teaching faculty at the Northwestern University Feinberg School of Medicine. He is also affiliated with Northwestern Lake Forest Hospital.
Before podcasts were even a thing, Dr. Kaskel hosted Lipid Luminations on ReachMD, building a library of more than four hundred shows featuring thought leaders in cardiology, lipidology, and preventive medicine.
He is the author of Dr. Kaskel’s Living in Wellness, Volume One: Let Food Be Thy Medicine, a book that blends evidence-based medicine with practical strategies for a longer healthspan. His current work focuses on rethinking the cholesterol hypothesis and exploring the infectious roots of atherosclerosis. More information is available at larrykaskel.com.
