> Of 1000 people treated with a statin for five years, 18 would avoid a major CVD event which compares well with other treatments used for preventing cardiovascular disease. Taking statins did not increase the risk of serious adverse effects such as cancer. Statins are likely to be cost-effective in primary prevention.
You should actually read the article. In particular:
> Fourteen trials recruited patients with specific conditions (raised lipids, diabetes, hypertension, microalbuminuria). All‐cause mortality was reduced by statins (OR 0.86, 95% CI 0.79 to 0.94); as was combined fatal and non‐fatal CVD RR 0.75 (95% CI 0.70 to 0.81), combined fatal and non‐fatal CHD events RR 0.73 (95% CI 0.67 to 0.80) and combined fatal and non‐fatal stroke (RR 0.78, 95% CI 0.68 to 0.89). Reduction of revascularisation rates (RR 0.62, 95% CI 0.54 to 0.72) was also seen.
So the evidence base is a collection of studies where most of the participants had at least one prior indicator of CVD or diabetes, and their outcome is a relatively weak benefit to all-cause mortality, CVD, CHD and stroke. For primary prevention, what you really want is a strong outcome in a study of people without any prior indication of disease [1].
I think the article posted by parent is exaggerating, but even the Cochrane review is pulling its punches here, saying specifically "cost-effective in primary prevention", instead of the stronger claim. Common jokes about putting statins in the water supply aside, there's not a ton of evidence for giving them to, say, otherwise healthy 20-somethings.
[1] Imagine the following, not-uncommon scenario: you have an otherwise healthy patient who is both pre-diabetic, as well as presenting with elevated cholesterol. Statins have a tendency to elevate blood glucose. So which risk do you choose?
Careful. You are correct at what we want for primary prevent. However for primary prevention we need much larger sample sizes and thus data is much harder to get.
Lack of data doesn't mean the treatment won't work. There is plenty of reason to think statins work for primary prevention even though it hasn't been proved yet. For most the side effects are acceptable, and the cost is low. Thus for most it is worth trying as primary prevention even if we don't have data to show it works. Remember you are playing with your own life here, and the best evidence we have is on the side of stains for primary prevention - this may change in the future when we get data of course.
> Lack of data doesn't mean the treatment won't work
In drug development, that is the default presumption, and rightfully so: almost nothing ever works.
> There is plenty of reason to think statins work for primary prevention even though it hasn't been proved yet.
Define "primary prevention" -- do you propose giving this to a healthy 20 year old with no other signs of illness? Younger? Should we "put it in the water", as they say? How about older patients? How old? Or, do you mean someone with symptoms? If so, then what about the case I cited (which is quite common in "primary prevention") where you have multiple things in tension?
The evidence provides no guidance here, and anyone who tells you otherwise is guessing. For what it's worth, though, we agree completely on the need for larger data. I think what drives me most batty about the "appeal to consensus" is that it's almost invariably used as a highbrow-lowbrow way of beating up on people who want to ask the question, which is the first step toward getting the answer!
It’s not that lowering cholesterol does not decrease heart disease, but the fundamental problem of heart disease is not cholesterol, it’s the inflammation.
Lowering cholesterol lowers the amount of oxidized cholesterol that is caused from inflammation. The fact is is that in inflammation is the fundamental disorder, not high cholesterol on its own.
For the last time. I am not saying that lowering cholesterol does not lower the risk of CVD. I am saying that it is oxidized cholesterol that causes CVD, and by lowering cholesterol you are also lowering oxidized cholesterol. Cholersterol good. oxidized cholesterol bad.
pubmed.ncbi.nlm.nih.gov/18625445/
Oxidative modification of low-density lipoprotein (LDL) is one of the earliest events in atherosclerosis.
The point of the original article is we should be focusing more on lowering oxidative stress (inflammation) instead of focusing on lowering cholesterol since 75% of people who have heart attacks have normal cholesterol.
Also, CVD mortality is lowered, but other causes of death increase.
Where we agree is that oxidation of LDL is part of the atherogenesis pathway.
However, I’m not aware of any evidence showing that higher oxLDL vs higher LDL entails greater risk. IIRC there is a paper that compared oxLDL to ApoB where ApoB was more strongly associated with risk, which doesn’t seem like it would be expected on your hypothesis.
The response to retention hypothesis and the mechanistic evidence supporting it point to oxidation being inevitable once ApoB tagged lipoproteins are trapped in the arterial wall. That being the case, it would be moot whether it entered the wall in an oxidised state or not.
So yes, oxLDL is one of the early stages of atherogenesis, but I’m not aware of any evidence that having LDL pre-oxidised before it’s trapped vs regular LDL increases risk.
I’m always open to new evidence that would change my view, but that’s my understanding of the research landscape at the moment.
MR looking at specific genes that reduce LDL-C through a variety of mechanisms, including some that lower inflammation, show basically identical reduction of risk per LDL-C lowered.
And remember that the largest ever study on saturated fat and cholesterol lowering was just not published by their original author because it didn't proove their hypothesis.
Your argument I responded to wasn't that the consensus of science is wrong, your argument was that the study is not valid because it was from the early 2010s
This is not a mainstream view of the science, and it's worth noting that this perspective is also not supported by the OP or by the JACC article that it's citing.
It's true that most doctors and pharmaceutical companies maintain that statins are effective. But there are plenty of statistically educated people that don't think they have much of an effect on all-cause mortality.
There are conflicting incentives here, and as usual we don't care about someone else's p value, we care about argmaxing our own utility functions.
> This is not a mainstream view of the science, and it's worth noting that this perspective is also not supported by the OP or by the JACC article that it's citing.
Your comment is an appeal to authority. While I have my problems with characterizing statins as dangerous drugs, the article is not particularly spicy. In particular, this part:
> Because the link between excessive LDL cholesterol and cardiovascular disease has been so widely accepted, the Food and Drug Administration generally has not required drug companies to prove that cholesterol medicines (such as statins) actually reduce heart attacks before approval. So drug companies have not had to track whether episodes like heart attacks are reduced.
...is true, and controversial only amongst people who don't know the evidence. Which, unfortunately, is many doctors and "experts".
In general, saying any variation on "experts disagree" is not a rebuttal to a question of medical evidence. You would perhaps be surprised to know how many practicing physicians have no idea what level of evidence backs the drugs that they prescribe.
The view among "authorities" is certainly something I find relevant in assessing a highly opinionated but thinly sourced medium article from someone who, respectfully, I've never heard of and know nothing about. Certainly it would be defeasible by a closer look at the research itself. But, barring that, it's a very useful heuristic.
I'm not suggesting you should take the medium article at face value either. Just that if you don't know enough to evaluate the evidence, you don't know enough to dismiss any particular opinion.
People are far too willing, today, to defer their thinking blindly to a consensus of opinions, but worse, to accuse anyone who also doesn't defer of being malicious.
I for one appreciated the clarification that it was not mainstream, since sneaking a random controversial take into a comment thread as if it was fact without noting that it's contentious is disingenuous.
No, they don't. If you don't know enough to argue on the merits, don't argue. A count of opinions is not an argument.
> sneaking a random controversial take into a comment thread as if it was fact without noting that it's contentious is disingenuous.
And again, you're justifying your judgment and dismissal based on hearsay. Saying "I refuse to believe it because experts disagree" is fine if you're unable or unwilling to look into an issue yourself, but in that case you have to realize you're basically ignorant.
I realize that we all go through life taking most things on faith, but that also means that you should not cling to the opinions of others as a substitute for thought.
yes they do. for one thing you do not make the rules around here; no one cares what you think counts as suitable grounds for arguing. For another, yes, authority has some merit. Doesn't make it fact, but certainly the prior we ought to assign for "medical authorities are correct" is quite high. Not certainty, but pretty confident, all else being equal.
edit: I see you added "I realize that we all go through life taking most things on faith, but that also means that you should not cling to the opinions of others as a substitute for thought."
Don't worry, nobody's doing that here. It's a question of weighting, not clinging. Maybe you mistook "this is not mainstream" to mean "this is definitely false because it's not mainstream"? It does not mean that. It is just helpful context for evaluating credibility.
> You're asserting that a extremely well-known logical fallacy is not a fallacy.
There are two distinctly different fallacies of appeal to authority (which overlap, since all of the second are also the first), this form is the form which is a deductive fallacy (appeal to status), but not the form that is a fallacy in inductive argument (which is appeal to false authority). It is important to distinguish them because while deductive fallacies are much more clear cut, they are also far less relevant to most real world debate, which rarely is about proving something is true by logical necessity assuming some set of axioms, but that is the only place that deductive fallacies are inappropriate, since all a deductive fallacy is is a form of argument in which the conclusion does not follow from the premise by logical necessity.
There is no logical fallacy in play here. Nobody is saying “the argument is wrong because of who said it”. When assessing the probable significance of an agglomeration of empirical data, it’s valuable to know what experts in the field think about the data and their consensus about the inferences we can draw from it—even if the consensus might be mistaken: because the consensus is usually right.
> There is no logical fallacy in play here. Nobody is saying “the argument is wrong because of who said it”.
The OP literally dismissed the parent based on nothing more than the opinions of others.
> When assessing the probable significance of an agglomeration of empirical data, it’s valuable to know what experts in the field think about the data and their consensus about the inferences we can draw from it—even if the consensus might be mistaken
I already conceded that, if you have no ability or capacity to think or investigate the issue yourself, it's perfectly fine to defer to the opinions of others. But in doing so, you remain ignorant on the matter.
> because the consensus is usually right.
No. I understand that's a comforting belief -- and even politically charged, today -- but it's just an assertion.
Well yes, exactly: it's just consensuses all the way down. Which is just another way of saying "I feel like it's right and you're wrong, even though I have no actual evidence either way."
But you have to separate the fallacy from it being supportive evidence of other data.
There is a difference from saying X must be true because Y person said it and they're an expert on Z. But when there is consensus between appropriate experts - such as researchers that specialize in this field - and it is in support of other specific evidence it is supporting evidence that the other specific evidence is compelling.
If I have 10 CPAs explaining a specific bit of the tax code to me and they are pointing out the specifics of the tax code, it is not fallacious to note that these people are experts and are pointing to specific evidence that supports their point.
as others have noted, you seem to be unaware of what exactly the fallacy refers to. You might want to look it up. It is not "citing an authority at all" but rather "citing an authority's opinion as though it were logical fact". Which nobody is doing here.
> I for one appreciated the clarification that it was not mainstream, since sneaking a random controversial take into a comment thread as if it was fact without noting that it's contentious is disingenuous.
(emphasis mine)
In other words, you didn't just passively ignore the parent (which would be fine), you posted about it, and not only that, you called it a lie. [1].
When you call something a lie like that, you're making an argument, so you'd better be prepared to bring the evidence.
[1] I realize that you're actually saying that it's "disingenous" that they posted this without some kind of disclaimer that it's a "controversial argument", but to the core of the issue: if you need that disclaimer, you aren't qualified to judge the content. For all you know, it isn't controversial at all.
... What is going on? Yes, that's what it means, that's why I used it. Notice it does not say 'lie' or anything directly synonymous with lying. It's related, sure, but not the same.
You can tell that it's not synonymous with lying because had you said to me "are you saying they're lying?" I would have said 'no'. This is always the case with semantic disagreements: if you want to know if someone intends a certain connotation, you can ask if they would agree with a rephrasing.
The disingenuousness is presenting a non mainstream theory as if it is fact. Anyone reading that initial comment probably has no idea whether "cholesterol and statins are suspect science". Had they said "some people think they're suspect science" there would have been nothing wrong. To claim they're suspect as a fact is disingenuous: it could be true, or it could be that the person posting it is one of those anti-establishment nuts who disagrees with consensus science about everything out of conspiratorial distrust and is constantly smuggling that stance into conversations all over the internet. Since it is very easy to present the state of affairs in a forthright manner, the only reason why someone would present them deceptively is (presumably) something like that. Hence knowing that the view is not mainstream is very useful for evaluating the motives of the original poster.
It's not evidence that they were lying, because that implies intent. No, probably they believe what they wrote. But it's evidence their ability to reason is suspect and possibly corrupted by some ideological motivation and so should be taken less seriously.
Not that I care, really, about any of this. Mostly this kind of antagonism is very frustrating and it's just kinda cathartic to try to shut it down.
My suggestion is that instead of engaging with commenters with your "oo! Logical fallacy! You broke the rules of arguing!" stance you instead try to find some way to productively engage with their actual thoughts. Perhaps figuring out why they said what they said instead of assuming anything you do not understand is a sign of a weak mind that needs to be corrected. You'll find people respond much more warmly to you if you do
You are confusing what "Appeal to Authority" fallacy is. Namely you are ignoring the fallaciousness of it.
The fallacy is where you use an authority in place of evidence. It is not fallacious to refer to consensus or experts.
Else, you end up basically in the "Do your own research"/vaccine denier/climate deniers/flat earth territory. Appeals to experts is not a logical fallacy. It's actually smart, because you get to leverage agreed facts (the earth is round) even though you've never actually been to space to see it for yourself.
The Medium blog you linked has 9 citations and none of them are actual scientific research. They're all news articles.
Regardless, the OP doesn't actually claim that cholesterol is not correlated with heart attack risk. If you read the entire article (not just the headline) it has a section explaining that the results are confounded by the fact that many patients were on statins already and therefore had lower measured LDL cholesterol than they would normally have due to their diet and lifestyle.
LDL isn't the only factor in determining heart disease risk. We've known this for a long time. Measuring LDL in heart attack patients can be misleading because it doesn't represent lifetime LDL area under the curve and they are more likely to be on LDL-lowering therapy than people with lower heart attack risk.
Correct, but if you read the news articles you'll see that they are reporting results from scientific articles and clinical trials. In other words, it is not the reporter's opinions.
Any cardiologist will tell you statins have saved millions of lives. And that they also have side effects that make them not an option for a significant chunk of the population.
Statins are not evil and they're not a scam, but we definitely need to replace them with something better.
Age-standardized cardiovascular mortality dropped steadily from 1975 to 2010 (with no particular discontinuity when statins were introduced), and has not budged since 2010.
Since 2010, however, the number of statin prescriptions has gone up 75%, and there have been proclamations that not only is the science "settled" because of a meta-analysis laundering past studies (that could never find a convincing benefit to lowered cholesterol), but that 1) twice as many people should be taking statins, and 2) maybe we should just put them in the water!*
What passes for science in medicine is usually bad, but it's exceptionally bad in the cases of the two classes of drugs that are the most prescribed, meant to be taken for the rest of your life, and coincidentally the biggest moneymakers: statins and SSRIs. They both also, even at best, claim very small benefits.
This thread is just going to consist of sloganeering and people calling you ignorant. Or a "denier," in order to compare disbelief in the tiny effect that statins claim (25-35%, under particular conditions) to disbelief in the Holocaust.
* Which was suggested every five years before any of these new, "conclusive" studies appeared. They'll just keep pitching it until they get that payday.
> Age-standardized cardiovascular mortality dropped steadily from 1975 to 2010 (with no particular discontinuity when statins were introduced), and has not budged since 2010.
Why would we favour cross sectional data over that produced by more rigorous methodologies?
> the tiny effect that statins claim (25-35%, under particular conditions)
25-35% reduction in one of the west’s leading killers is tiny? Wild.
> Statins can be beneficial in patients who have already suffered heart attacks. Cholesterol lowering is not the reason for the benefit of statins. If it was, lowering cholesterol via any means should have produced the same benefit, but it doesn’t.
What a blatant lie! Ppcsk9 inhibitors have produced excellent results, even better than statins.
Vytorin is a combination of cholesterol-lowering drugs, one called Zetia and the other a statin called Zocor. Because the two drugs lower LDL cholesterol by different mechanisms, the makers of Vytorin (Merck and Schering-Plough) assumed that their double-barreled therapy would lower it more than either drug alone, which it did, and so do a better job of slowing the accumulation of fatty plaques in the arteries - which it did not.
Not really, the evidence that ldl causes heart disease and statins prevent deaths is very, very, very strong (lots of clinical trials, lots of causal evidence e.g. Mendelian randomization). LDL is extremely harmful!
So you are saying the human body manufactures a substance that is extremely harmful to the body. And yet lowering it artificially can lead to issues such as loss of short term memory. The body needs cholesterol! You could qualify your argument by saying that excess LDL is harmful.
The body needs SOME. Evolution doesn't care about when you die, just that you reproduce first. Even the highest cholesterol cases generally have kids old enough to have their own kids before they die. That is enough for evolution to not care.
As someone who lost the genetic lottery (has the high cholesterol gene) you bet I care. There is every reason to think that treating cholesterol will increase my lifespan - I'm hoping for quite a few more healthy years.
The body can produce needed cholesterol locally just fine. The PCKS9 inhibitor trials show that having basically no serum LDL is not harmful. People that have the genetic mutation that results in no PCKS9 have extremely low rates of CVD
Extraordinary claims require extraordinary evidence. The cholesterol to heart disease link is one of the best attested in medical science [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]
And yet when making this very extraordinary claim, the author fails to cite any quantitative data for or against. He does not even attempt to build a qualitative argument by proposing a mechanistic theory of why cholesterol is unlikely to be causative of heart disease. Then he goes on to claim that doctors don't have hard evidence to show that statins reduce the incidence of heart disease, despite the fact that such evidence exists [5]. The post is just 10 paragraphs of fluff that boil down to 'don't trust the medico-industrial complex'
Honestly, I think that blog post is a litmus test on scientific literacy - What convinces you more, data and numbers and charts and tests of statistical significance, or rail-against-the-machine rhetoric and a few scary sounding quotes provided without the associated context?
> The cholesterol to heart disease link is one of the best attested in medical science
What about this:
Cholesterol lowering is not the reason for the benefit of statins. If it was, lowering cholesterol via any means should have produced the same benefit, but it doesn’t. One obvious way to confirm this is to find therapies that lower cholesterol by different means (i.e., other than statins) and see if they, too, prevent heart attacks. They don’t. See: https://www.nytimes.com/2008/01/27/opinion/27taubes.html (Some will discredit the author Gary Taubes without addressing the points he is raising.)
It's a bad blog post for sure. However, I've a few smart people say that lower cholesterol may not be what makes statins powerful: it's the anti-inflammatory properties. I'm too lazy to find papers right now.
Yes, there is certaintly data to make that argument. The argument that inflammation is a better predictor of heart disease than cholesterol is a reasonable one. On the other hand the argument that cholesterol is not a good predictor of heart disease and cholesterol lowering therapy is a fraud is not reasonable in the face of the evidence.
The blog is merely pointers to, and excerpts from, other articles on sources such as New York Times and Bloomberg. The blog post can't be bad unless the original sources it cites are bad. Which ones are bad?
> The blog post can't be bad unless the original sources it cites are bad
The blog post misrepresents some of the sources by exaggerating the certainty of the claims and ignoring any evidence contrary to the point it's making.
https://medium.com/@petilon/cholesterol-and-statins-e7d9d8ee...