The People's Perspective on Medicine

Doctors Battle Over High Cholesterol and Blood Pressure

Half the population of the United States has high cholesterol and blood pressure according to the official guidelines. Why is this so controversial?
Statins cholesterol statin drugs

Ask doctors what key measurements they rely on to assess the overall health of a patient and you are likely to hear about high cholesterol and blood pressure. Elevated blood sugar is not far behind. Controlling these key metrics is considered essential for good health. In general, the prevailing belief is that high cholesterol and blood pressure must be brought into the normal range. Lower is almost always thought to be better.

What About Lifestyle Changes?

We frequently see guideline committees give lip service to lifestyle changes. That’s a step in the right direction. Unfortunately, there are relatively few physicians who have been trained as health coaches. In practical terms, they do not have the skills or the time to motivate, monitor and facilitate exercise, weight loss and healthy eating strategies.

Because these kinds of lifestyle changes are hard for people, they often are not able to lower their high cholesterol and blood pressure into the normal range. As a result, getting high cholesterol and blood pressure lower almost always boils down to prescriptions for medicine.

The Battle Begins:

When you delve into the details of controlling high cholesterol and blood pressure, you discover that there are different health perspectives. Sometimes patients feel as if they are caught between warring camps. How high is too high? What’s considered normal? How low should cholesterol, blood pressure and blood glucose go? Physicians do not always agree.

Lies, Damned Lies and Statistics:

You’ve no doubt heard the phrase, “Lies, damned lies, and statistics.” It implies that people can manipulate numbers to mislead.

Mark Twain used the phrase enough that many people have attributed it to him. In truth, no one seems to know who first coined this term.

According to Wikipedia, the first time this saying was found in print was in the National Observer, a British newspaper. A letter to the editor was published on June 13, 1891, stating:

“Sir, —It has been wittily remarked that there are three kinds of falsehood: the first is a ‘fib,’ the second is a downright lie, and the third and most aggravated is statistics.”

Confirmation Bias:

These days scientists have another way of describing misleading statistics. It is called confirmation bias. In other words, we see what we want to see and ignore that which does not conform to our perspective.

The ancient Athenian historian Thucydides wrote about this problem over 2000 years ago. Here are some quotes attributed to Thucydides

“…the search for truth strains the patience of most people, who would rather believe the first things that come to hand.” [Wikipedia]

Then there is this one:

“It is the habit of mankind to entrust to careless hope what they long for, and to use sovereign reason to thrust aside what they do not desire” [goodreads]

High Cholesterol and Blood Pressure:

Most patients assume that health professionals are in agreement when it comes to treating high cholesterol and blood pressure. These are, after all, the pillars of standard medical care.

The Cholesterol Conundrum:

Let’s start with cholesterol. The American College of Cardiology (ACC) and the American Heart Association (AHA) issued guidelines in 2013. The recommendations would put nearly all men over 64 and women over 70 on a statin-type cholesterol-lowering medicine. That’s even if they:

  1. Do not smoke
  2. Have no family history of heart attacks or strokes
  3. Exercise regularly
  4. Follow a heart healthy diet
  5. Have beautiful numbers like total cholesterol of 180, blood pressure of 120/75 and no signs of heart disease.

The guidelines issued by the ACC and the AHA were presumably based on science. The cardiologists reviewed the literature and came up with their recommendations. We know these well-meaning health professionals want to prevent heart disease. The only problem is that there are other well-meaning physicians who have also reviewed the literature and come up with different conclusions.

A Contrarian View of Cholesterol:

Most health professionals welcome guidelines for prescribing medications like statins. But some have examined the same evidence and come to different conclusions.

One cardiologist and lipid specialist has challenged his colleagues. He suggests that they may be swayed by confirmation bias (QJM, online Nov. 2, 2017).

When it is done consciously and deliberately, we might call this type of selectivity regarding studies “cherry-picking.” But Dr. Robert DuBroff is accusing the guideline writers of something less malicious but more insidious: gravitating to the evidence that supports their position and overlooking data that might refute it.

Dr. DuBroff notes that:

“For example, in one randomized controlled trial (RCT) there was no benefit of atorvastatin therapy in extremely high risk asymptomatic patients with coronary calcium scores >80th percentile. Similarly, selected RCTs of statins in other high-risk populations – diabetes mellitus, chronic kidney disease, ischemic heart failure, post-MI [myocardial infarction], and post-CABG [coronary artery bypass graft] – have also reported no clinical benefit.”

Statins and Older People: The Controversy Rages On

Many older people are prescribed statins in the hopes that drugs like atorvastatin, lovastatin, rosuvastatin and simvastatin will prevent cardiovascular (CV) events and reduce mortality. Dr. DuBroff takes a colleague to task:

“The former president of the National Lipid Association advocated for statin usage in the elderly in his 2015 Journal of the American College of Cardiology editorial. He cited the PROSPER study, a RCT [randomized controlled trial] of statin therapy in the elderly, which reported a reduction in CV events but not mortality.
However, he neglected to reference the only other published RCT of statins specifically in older patients (CORONA) that reported no significant reduction in mortality or CV events.”

Dr. DuBroff points out that physicians often become overwhelmed by all the studies, guidelines, medications and warnings. They look to experts for informed opinions:

“They expect these opinions to be comprehensive, balanced, unbiased, and unsullied by financial conflicts. Unfortunately, these examples illustrate that some expert opinions fall short of these standards. Furthermore, recent reviews affirming the benefits of cholesterol reduction have largely ignored nearly four dozen RCTs of cholesterol lowering that have failed to reduce mortality or cardiovascular events. To ensure balance and fairness medical experts must incorporate the entire empirical record, not simply the evidence that substantiates their own viewpoint. We must also acknowledge that financial relationships between the pharmaceutical industry and some medical experts can engender both conflicts of interest and bias that can jeopardize the credibility of their opinions.”

Other Cardiology Voices:

Dr. DuBroff is not the only cardiologist challenging the statin enthusiasts. An editorial in JAMA Internal Medicine by cardiologist Rita Redberg and her colleague Dr. Mitchell Katz is titled “Statins for Primary Prevention: The Debate is Intense, but the Data Are Weak” (Nov. 15, 2016). They examined the data and concluded:

“Using the current data, the decision aid shows that of 100 people who take a statin for 5 years, only 2 of 100 will avoid a myocardial infarction [heart attack], and 98 of the 100 will not experience any benefit. There will be no mortality benefit for any of the 100 people taking the medicine every day for 5 years. At the same time, 5 to 20 of the 100 will experience muscle aches, weakness, fatigue, cognitive dysfunction, and increased risk of diabetes.”

Let’s put this in a somewhat less scientific arena, such as horse racing. If we asked you to bet a month’s salary on a long-shot horse that had a 1 in 50 chance of winning the big race, you might think twice about betting. If only 2 healthy people out of 100 will avoid a heart attack after five years of statin treatment, that’s a 1 in 50 chance of success.

Of course, what people really want is to delay their likelihood of dying prematurely. According to Dr. Redberg, the odds that statins can do that are hard to detect. This is for what doctors call “primary prevention.” Except for elevated cholesterol levels, they are otherwise healthy. The story is more complicated for those with heart disease.

Lowering High Cholesterol AND Blood Pressure:

Cholesterol is not the only arena in which confirmation bias might have shaped recommendations. The most recent guidelines from the American Heart Association and the American College of Cardiology urge doctors to make sure all their patients get their blood pressure to 130/80 or lower (Circulation, Nov. 13, 2017).

This goal, 10 points lower than previously recommended, will be a challenge for many people. Of course, if it prevents large numbers of strokes and heart attacks, it will be worth the effort. To achieve the lower than 130/80 goal, patients may have to take many blood pressure medications.

A Different Perspective:

How confident should we be about the benefits of lowering blood pressure to this point? A meta-analysis published in JAMA Internal Medicine (Nov. 13, 2017)  indicated that such an aggressive approach might not save lives.

These researchers found that lowering systolic blood pressure (SBP) over 140 before treatment did make an important difference. But otherwise healthy people whose SBP started under 140 did not appear to benefit from medications to lower it further.

A Heretical Analysis of Blood Pressure Treatment:

The highly regarded Cochrane Collaboration uses strict criteria to evaluate medical research. On August 15, 2012, this independent organization published a challenging article titled “Benefits of Antihypertensive Drugs for Mild Hypertension Are Unclear.” The conclusions:

“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”

A Newer Cochrane Analysis of BP Treatment:

The objective investigators at the Cochrane Collaboration recently tasked themselves with an important challenge (Cochrane Database of Systematic Reviews, Aug. 16, 2017). They noted that most of the systematic reviews of antihypertensive drug therapy have been done in people over the age of 60. They wanted to know the impact of drug treatment on people 18 to 59. With the new guidelines, a great many of these folks will likely be put on BP meds. How good is the evidence that such treatment will produce meaningful benefit?

The Cochrane researchers located seven studies involving 17,327 participants. These were healthy people with mild to moderate high blood pressure. Here is what they found:

“Based on five studies, antihypertensive drug therapy as compared to placebo or untreated control may have little or no effect on all-cause mortality (2.4% with control vs 2.3% with treatment; low quality evidence; Based on 4 studies, the effects on coronary heart disease were uncertain due to low quality evidence. Low quality evidence from six studies showed that drug therapy may reduce total cardiovascular mortality and morbidity from 4.1% to 3.2% over five years…The effects on blood pressure varied between the studies and we are uncertain as to how much of a difference treatment makes on average.”


“Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced.”

The People’s Pharmacy Perspective:

The new guidelines from the AHA and ACC clearly contradict the Cochrane analysis. Which perspective is “right”? Perhaps neither, though we tend to believe the Cochrane independent investigators when they state repeatedly that the evidence is of “low quality.” In other words, decisions are being made for millions of people based on poor quality research. We were also astonished to read that “all-cause mortality and coronary heart disease were not reduced” after antihypertensive drug treatment.

Guidelines should not be treated like dogma. Whether it’s blood pressure, cholesterol or some other metric, physicians should consider each patient as an individual. Many people can tolerate statins and blood pressure medicines without experiencing any side effects. They lower their high cholesterol and blood pressure successfully and may reduce their risk of a heart attack or stroke. (Please note the word “may.” Given the Cochrane Analyses, this is not a slam dunk.)

Others, however, cannot tolerate statins. The muscle pain and weakness are daunting and prevent them from exercising. Some patients develop dizziness from too many antihypertensive pills. A fall can lead to disability or death. In such cases, other treatment options need to be explored.

Here are links to recent articles from The People’s Pharmacy:

Why Lower Your Blood Pressure If It Was Measured Incorrectly?

How to Lower Blood Pressure Without Drugs

You can find more information at: Graedons’ Guide to Cholesterol Control and Heart Health and Graedons’ Guide to Blood Pressure Treatment.

Share your thoughts about the Guidelines below in the comment section.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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I’ve been on pravastatin and valsartan for several years. This combo has worked exceptionally well for me after many attempts with different drugs. I am prediabetic but my numbers have actually come down the last 2 years. I think sometimes it is easier to blame a med than to realize one’s lifestyle and age could be major contributors.

I appreciate the research suggesting association between diabetes and statins. However with a strong family history of heart disease, I work with my cardiologist and trust his approach.
Every med has risk. Aspirin would probably be a prescription drug only if entering the pharmacy world today. I am not discounting the info. Just trying to suggest that a balanced approach with eyes wide open generally minimizes risk.

I just discontinued my second statin drug on account of numerous side effects. This article makes me worry about my blood pressure medicine which is olmesartan.

I read an article written by a doctor who says cholesterol is not too high until it is above 300.

The promoting of flu shots along with this makes me not trust doctors who seem to bend to the will of pharmaceuticals. I got a flu shot once and got sick. Never again.

A lot of people don’t realize that the side-effects from some blood pressure medications can be similar to an intolerance to statins. In vulnerable individuals, Angiotensin Receptor Blockers, ACE Inhibitors, Beta-blockers, and Calcium Channel Blockers can all negatively affect the P450 cytochrome system, involved in drug (and other substrate) metabolism – also ATP formation, which is the energy currency of every cell. My husband began to suffer a serious amount of muscle pain and atrophy while taking an ARB. He even began to have trouble standing and walking. He discontinued (under the guidance of our physician) this drug and over several months, he fortunately regained his mobility and strength. Switching to a Calcium Channel Blocker caused different but somewhat similar symptoms – muscles and tendons easily prone to tearing under minimal stress.

It is unfortunate that so much profit motive drives prescribing drugs. For one thing, it doesn’t allow for individual tolerances or intolerances to medication (this information is only obtained after-the-fact when side-effects surface). For another, it is possible, it seems to me, that some people might do better with higher cholesterol or blood pressure than others. But we don’t know who those individuals might be because there is no compelling monetary reason to identify them.

It is obviously good to keep one’s blood pressure within a healthy range, but if the trade-off is loss of mobility or physical activity, then the cure is worse than the disease. Anyone taking any of these hypertensive medications who is experiencing muscle pain, muscle wasting, or easily injured connective tissue might want to consider that the medications (or interactions involving multiple medications) could be the problem. But getting a physician to believe you could be challenging. We were fortunate that my husband’s provider was open-minded.

Unfortunately, these guidelines hold so much sway over most doctors that patients aren’t given a chance to let lifestyle and dietary changes make a difference. Too many doctors assume that their patients are too lazy or uninformed to take this all-important step. Doctors also don’t have the knowledge, patience, or time to guide their patients to better health without drugs.

Truly, the risk of being sued is also a big influence in what recommendations a physician may make.

What are your thoughts about using berberine and quercetin?

Excellent information

It would seem to me that, with the increased use of these types of drugs and many others meant to make us healthier, we would be seeing record levels of good health in our population. And yet that doesn’t seem to be the case. The health professions need to divorce themselves from Big Pharma, which is a corporate entity with profits as their driving force, not the general well being of the people

Excellent article — Thank, You!

I was given atorvastin 10mg – could not function. Doctor then put me on Welchol625mg – same result and cost me a bundle of money. Came to the conclusions – no more statins. Also, after observing many of my contemporaries on statins I decided they were close to dementia after 3 or 4 years. No more! I am 75 take care of a home and 2 acres of grounds, exercise and have healthy habits. Starting to think that “statins” are the fad of the current time and too many are put on them. My cholesterol was borderline and my BP was 122 over 70.

It is hard to take a doctor’s advice to utilize medications for blood pressure and cholesterol when there is so much controversy. I had one doctor tell me that he does not take such medications himself because he believes that many of the studies are biased.

Most doctors are taught how to dispense drugs, not health. If big pharma has its way, soon all of us will be deemed sick from something or other and require a drug. What a joke. To the extent that a disease brings in big bucks, there will never be a full cure for that disease from big pharma. Cancer and diabetes are the perfect examples.

I truly appreciate your analysis in this ongoing debate regarding BP and cholesterol.
Thank you Graedons for helping me see through the fog of medical jargon and bias.
Clearly there are no easy answers but your educated ‘common sense’, is a valuable resource.

I have been told as a diabetic I need to take both cholesterol and high blood pressure medicine. My BP and cholesterol numbers are fine but as a diabetic this is a precaution. Low dose BP medicine is taken to help my kidneys which I’m fine with. However, last year I told my dr I wanted to discontinue the statain because I felt the drug was causing memory loss. After a few months I felt my thinking had improved and glucose numbers in the AM were in normal reading. After a year my doctor put me back on a station and I believe this drug causes high glucose readings in the morning. I have gone from 80-90 reading to 176-190 in the morning.
Do you have any knowledge of this problem? Has any research shown this may be a side effect?

Beth, statins can lead to elevated blood sugar:

I think that if I was selling a product I would want every person to buy it.

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