Statins — What They Actually Do
The most studied class in medicine
Statins block HMG-CoA reductase — the rate-limiting enzyme in cholesterol synthesis — lowering LDL-C and ApoB substantially. Decades of trials across hundreds of thousands of patients have settled the big question: statins reduce cardiovascular events and mortality, in primary and secondary prevention.
The relative vs absolute risk gap
Statins reduce cardiovascular events by ~25% relative to placebo. In a high-risk patient (e.g. post-MI) that's a huge absolute benefit. In a low-risk 45-year-old with normal ApoB the absolute benefit over 10 years is small — which is why shared decision-making matters rather than blanket prescribing.
Side effects — honest numbers
In blinded trials, muscle symptoms occur at roughly the same rate on statin and placebo (~15% each). Diabetes risk increases slightly (about 1 extra case per 255 patient-years). Serious side effects (rhabdomyolysis, liver injury) are rare. Most reported muscle symptoms don't reproduce on rechallenge.
True or False
All statins are equivalent.
The ApoB-aware way to think about statins
The question isn't "do I have high cholesterol?" It's "given my ApoB trajectory, cumulative exposure, Lp(a), CAC score, and family history, does lowering ApoB by 30–50% now change my 30-year outcome?" For most people with ApoB > 80 and any other risk factor, the answer is yes.
Key Takeaway
Statins work. Their side-effect profile is better than popular perception. The right question is about cumulative ApoB exposure and 30-year risk, not this year's cholesterol reading. Most people in their 40s with ApoB > 80 and any risk factor benefit from starting one.