Cholesterol & Lipid Management
High cholesterol doesn’t automatically mean you need a statin.
A balanced, evidence-based approach — in the middle of the cholesterol civil war.
The Debate
There is a civil war between cholesterol experts. Most patients are caught in the middle.
There is currently a huge amount of confusion in the public space around high cholesterol and its effects on cardiovascular health. In fact, if we are honest, there is a ‘civil war’ between so-called cholesterol experts with exaggerated agendas from both in the media and online which is difficult for the public to decipher.
Camp 1
The historical and usually mainstream academic and medical community, backed by large-scale industry-sponsored clinical research trials, believe and argue that the link between high cholesterol and cardiovascular disease (including angina, heart attacks and strokes) is fundamental.
As a result, current UK guidelines place cholesterol as the biggest risk factor for heart attack. This means that the population-based risk calculators (Q risk) used by doctors are heavily weighted towards your cholesterol measurements. If your 10-year risk of a cardiovascular event is over 10% (which it is for many simply as a statistical consequence of aging) then statin therapy is recommended as ‘primary prevention’, i.e. to prevent a future heart attack or stroke.
With 60% of adults over the threshold that would be defined as normal cholesterol in these guidelines, the majority require statin treatment. This camp are pro-statin and some have suggested that the benefits are so significant (and downsides / side effects so minor) that it should be supplemented in tap water.
Camp 2
The opposing camp come from a variety of backgrounds and include doctors, researchers, investigative journalists and alternative therapists. This group argue passionately that cholesterol is a fundamental physiological requirement for a well-functioning mind and body and that there is no or very little link between ‘high cholesterol’ per se and cardiovascular health problems or benefit from statins.
They suggest that the evidence has been manipulated by industry and conflict, highlighting the fact that Atorvastatin is the biggest mega-blockbuster drug of all time in terms of revenue generated for big pharma. Within this group there will be patient representatives who are convinced of long-term health problems affecting the brain, nervous system or muscles as a consequence of previous statin use.
The Dietary Debate
The dietary advice is just as contested.
The dietary perspectives further confuse the debate. The historical dogma that is still ingrained in most medical information, patient literature and advice is to go ‘low-fat’, eat high-fibre breakfast cereals and switch to margarine and Benecol to lower cholesterol. Despite this, you will be told that you can only expect to lower your cholesterol by around 10%.
A Different Approach
Population-based advice for an individual problem.
While the accepted wisdom is to take a statin to lower cholesterol, there are more people now suggesting that this approach is not correct, that the data has been misinterpreted and that we are actually overprescribing statins in this group.
The Personalisation Tool
CT imaging changes the conversation entirely.
For this group of people, we use advanced non-invasive imaging techniques (including CT coronary calcium scoring and angiography) to help determine their individual risks and the best options for them to safely, effectively and reliably lower their cholesterol (or indeed not to worry about their cholesterol).
Cholesterol alone does not define cardiovascular risk. CT imaging allows us to determine whether atherosclerosis is actually present — and how significant it is — enabling a far more personalised and accurate approach to prevention.
CT coronary angiography is the primary personalisation tool. It allows direct visualisation of whether atherosclerosis is actually present, regardless of cholesterol level. This changes the entire conversation from population risk to individual reality.
Coronary calcium scoring is useful in selected cases as a first step — CT angiography supersedes it in most situations. Advanced lipid fractions including ApoB and lipoprotein(a) provide a more precise picture of cardiovascular risk than standard cholesterol panels, and are used selectively where standard tests do not fully explain the clinical picture. The Caristo Heart platform provides AI-assisted analysis of coronary inflammation from CT imaging, identifying early disease before visible plaque develops.
What We Find
Most patients leave with an answer. Not just a number.
Confident reassurance
The vast majority of people that I see will typically have very high cholesterol, but no other cardiovascular risk factors. In the vast majority of cases, we can confidently tell them that they don’t need a statin, nor do they need to worry about their cholesterol profile. This is often a huge relief to people, as their cholesterol would otherwise be hanging over them in the future, causing anxiety every time they see their doctor. Rather than telling them they need to take a statin, we are able to give them closure on the subject.
Clear evidence for treatment
Equally, there are people we can provide with robust data to suggest that they would, at a personalised level, benefit from pharmacological treatments and provide closure that they are doing the right thing on the balance of benefit and risk. This then becomes an informed, shared decision.
Targeted dietary programme
There is a third group (and we are very passionate about these patients) who do need to make a change but do not need to commit to tablet treatments. These patients can significantly improve their cholesterol profile (and associated risk factors) through prescribed and targeted dietary and lifestyle treatments.
There is an urban myth in the medical community that you can only lower your cholesterol by 10% through dietary change. This is absolutely wrong. In an unselective population, you can expect to reduce it by at least 20%, and if you select the right patients, you can reduce it a lot further. Frankly, a lot of the information that’s out there at the moment about low-fat diets and avoiding saturated fat is historical. We provide people with a personal dietary approach based on current up-to-date evidence and thinking.
This personal, tailored approach to the management of high cholesterol is transformative for so many of the people I see. We are able to give them a robust answer about whether or not they need to take a statin, or whether dietary and lifestyle changes will be sufficient.
It should be said of course that in some cases, the evidence and test data shows that somebody will benefit from taking a statin. In these cases, I have no hesitation in advising them of this. Again, it all comes down to a tailored approach. One size does not fit all for so many medical treatments, and this is certainly the case for the management of high cholesterol.
The question is not whether statins work. It is whether you specifically need one.
Speak with Tash — 01761 422287