You’re Not Crazy to Question Statins

A new paper in JACC: Cardiovascular Imaging has stirred up sharply divided opinions. Let’s first walk through the study and its limitations and then zoom out to talk about the broader implications.

Imagine a hammer.

It’s a tool — a great one if you want to drive a nail.

But what if I try to open a jar of pickles with a hammer?

Oops! That didn’t work.

The point is obvious. You don’t need an MD degree to see it: the tool should fit the job.

That’s as true for hammers as it is for medications. And today we’re talking about one of the most profitable—and controversial—tools in medicine: statins.

A new paper in JACC: Cardiovascular Imaging has stirred up sharply divided opinions. Some see it as further evidence we should be cautious about over-prescribing statins—especially for primary prevention in patients without existing heart disease. Others call it a scientific misstep and even a danger to public health.

So, what’s actually going on?

Let’s first walk through the study and its limitations and then zoom out to talk about the broader implications.

The Study in Brief

This paper set out to evaluate whether statins reduce major adverse cardiovascular events (MACE), such as heart attacks or death, in patients with varying degrees of cardiovascular disease, as assessed by CT angiography (CTA).

The bottom line? Statins were associated with a reduced risk of MACE in those with more severe disease but showed no significant benefit in those without cardiovascular disease.

Let’s get into the details.

The study included 11,026 patients (average age: 59, roughly half male, half female) who underwent CTA scans and were followed for a median of 3.33 years.

As a taste of the data:

• In patients with obstructive coronary disease (defined as >50% blockage in a vessel), statins were protective. The adjusted hazard ratio (HR) was 0.80—a 20% reduction in risk.

• In patients with minimal or no disease (based on Segment Involvement Scores or CAC scores), statins showed no benefit. Adjusted HRs were 1.02 and 1.01, respectively.

*A hazard ratio, or HR, compares the rate of a particular event—like heart attack or death—between two groups over time. An HR of 1.0 means no difference; below 1.0 suggests reduced risk with treatment; above 1.0 suggests increased risk.

You can also see the main figure, below.

The graphs show MACE risk reduction from statin use as a function of calcium score (left) and segment involvement score (right). At lower calcium scores and lower segment involvement scores statins do not provide any significant.

The punchline is this:

Statins reduce risk in patients with established and advanced cardiovascular disease. In patients without cardiovascular disease there was no benefit.

But that’s just the warm-up. The real conversation starts here.

In the full version of this letter, we’ll dive far deeper into the statin literature and review:

• Why these findings matter — and why they’re not as new as they seem

• The real pros and cons of statins you need to understand

  • LDL and ApoB

  • Insulin Resistance

  • GLP-1

  • Mitochondrial Health

• And how social, economic, and industry forces shape what makes headlines—and what gets left out of your doctor’s office

Let’s go deeper and arm you with information. By the end, I promise you’ll know more about statins than most doctors.