Statins for Almost Everyone: Put Statins in Salt-Shakers?

Years ago, a prominent cardiologist made what we assumed was a tongue-in-cheek suggestion: replace the salt-shakers on restaurant tables with “statin-shakers.” Judging from the new cholesterol guidelines, statins for almost everyone may no longer seem quite so far-fetched.

This physician/researcher was so enthusiastic about statin-type cholesterol-lowering drugs that he thought they should become nearly universal. Sprinkle a little atorvastatin on your scrambled eggs. Add a dash of rosuvastatin to your soup. Perhaps the water department could take care of everyone else by adding simvastatin to the municipal water supply.

The cardiologist we were interviewed decades ago embraced the benefits of statin-type cholesterol-lowering drugs so thoroughly that he thought they should become semi-mandatory. Hence his joke about statin-shakers instead of salt-shakers.

We chuckled uncomfortably at the time. Now we are not so sure his idea was entirely a joke. The most influential cardiologists in the United States have pretty much adopted his philosophy.

Do New Guidelines Suggest Statins for Almost Everyone?

New cholesterol guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) are moving in the direction of statins for almost everyone. The 2026 ACC/AHA Dyslipidemia Guideline substantially increases the number of people eligible for statin therapy. They recommend assessing cardiovascular risk in adults from age 30 through 79, rather than concentrating primarily on people between 40 and 75.

The guidelines also lower the risk thresholds at which statin treatment should be considered. A 10-year risk of 3% is now classified as “borderline,” 5% as “intermediate” and 10% or greater as “high.”

For adults between 30 and 59, clinicians are also encouraged to look far beyond the next decade. A person with a low 10-year risk may still qualify for treatment if the PREVENT calculator estimates at least a 10% risk of cardiovascular disease over 30 years.

That is an enormous change. It means that some apparently healthy people in their thirties or forties might be encouraged to begin medication today… to reduce the possibility of a heart attack several decades from now. If the protection were ironclad and there were no side effects, that might make sense.

Many healthcare professionals seem to believe that statins are extremely effective at preventing heart attacks and strokes and prolonging life. They may have confused relative risk reduction (RRR) with absolute risk reduction (ARR). We will look at the data momentarily. Some prominent cardiologists and researchers have argued that many reported statin side effects may be attributable to a “nocebo effect.” That is to say, they believe statins do not cause most people any unpleasantness. More about that too.

Statins for Almost Everyone Is Not a Misnomer

An analysis in JAMA (July 20, 2026), estimated how many people should be taking statins based on the new guideline. According to my interpretation of their data, nearly one third of 156 million American adults without a diagnosis of heart disease have LDL cholesterol levels above the desired goal. That would equal about 50 million people.

Another 17 million people already dealing with heart disease (also known as ASCVD or atherosclerotic cardiovascular disease) have LDL cholesterol levels above the new ACC/AHA desired goal. Many are already taking statins or another lipid-lowering medicine but remain above the recommended goal.

Combine the two groups—those with and without ASCVD—and you get roughly 67 million people whose LDL cholesterol is above the new guideline goals. Many would be candidates for starting or intensifying cholesterol-lowering treatment.

What Are the New LDL Cholesterol Goals from the ACC/AHA?

The guidelines have brought back specific LDL cholesterol goals.

They vary according to a person’s cardiovascular risk:

• Low risk: LDL below 160 mg/dL
• Borderline or intermediate risk: LDL below 100 mg/dL
• High risk: LDL below 70 mg/dL
• Very high risk with established ASCVD: LDL below 55 mg/dL

The guideline is available here.

Another Analysis Also Suggests Statins for Almost Everyone

A separate analysis published in the same issue of JAMA (July 20, 2026) used the National Health and Nutrition Examination Survey (NHANES) data representing 177.7 million adults between 30 and 79.

Here are the findings. Please strap on your seatbelt! The numbers are extraordinary!

“…it was estimated that the 2026 guideline would expand statin eligibility to 21.5 million adults not previously recommended statins. An estimated 87.5 million US adults, 56.6% of the target population, are eligible for statins, including more than 93% of adults aged 70 to 79 years.”

“Meaning

“The 2026 dyslipidemia guideline substantially expands the US population eligible for primary prevention statin therapy.”

“Primary prevention” refers to people who have not been diagnosed with ASCVD and have not experienced a cardiovascular event. Their eligibility may be based on cholesterol levels and other cardiovascular risk factors.

Numbers can be numbing. Most people tune out. Let me ask you for complete attention, though. This will only take 15 seconds of your time.

Here is a breakdown of the analysis:

• 87.5 million adults between 30 and 79 are now “eligible” for statins
• 93% of adults 70-79 years of age are “eligible” for statins
• 85% of adults 60-69 are “eligible” for statins
• 11% of adults 30-39 are “eligible” for statins

Younger adults with a relatively low risk (3.1%) for experiencing a heart attack over 10 years are now “eligible” for a statin.

At the risk of sounding like a broken record, let me quote the authors one last time:

“More than 93% of adults aged 70 to 79 years and 85% of adults aged 60 to 69 years are eligible for primary prevention statin therapy compared with 11% of adults aged 30 to 39 years.”

It is hardly any wonder that almost everyone over the age of 60 is being “offered” a statin prescription. In some cases, we have heard that if a patient refuses to take a statin or some other cholesterol-lowering drug, they have been “fired” by their physician.

Eligibility is not the same as a command to swallow a pill. The guideline authors repeatedly emphasize individualized decisions and shared decision-making. Nevertheless, when well over half the adult population qualifies for medication, statins for almost everyone begins to sound less like satire and more like national health policy.

Why Aren’t More People Embracing Statins?

Cardiologists and drug companies may look at the number of people not taking statins and see a massive missed opportunity. They envision thousands of preventable heart attacks and strokes. Some insist that millions of people would be protected from cardiovascular disease if they only followed the new guideline.

We look at the same numbers and ask another question: How much benefit can an individual patient realistically expect?

Statins for Almost Everyone—but How Much Does Everyone Benefit?

There is no question that statins lower LDL cholesterol. There is also convincing evidence that they reduce cardiovascular events, particularly among people who have already experienced a heart attack, stroke or other manifestation of atherosclerotic cardiovascular disease.

That is called secondary prevention. Such people have a great deal more to gain because their underlying risk is already so high.

The situation is less dramatic for someone who has never had cardiovascular disease and has a relatively low risk of experiencing a heart attack or stroke in the foreseeable future. That is primary prevention.

The newly eligible group in the JAMA analysis had an average estimated 10-year cardiovascular risk of just 3.1%. The average risk among people who would already have qualified under the old guidelines was 6.1%.

In other words, much of the expansion is occurring among younger, lower-risk people. They may be asked to take medicine every day for decades in the hope of preventing an event that was relatively unlikely to occur during the next 10 years in the first place.

That does not mean the medicine is worthless. It does mean that patients deserve to know the magnitude of the likely benefit in terms they can understand.

Statins for Almost Everyone and the Relative-Risk Magic Trick

Suppose 2 people out of every 100 suffer a heart attack without treatment. In the drug-treated group, only 1 person out of 100 has a heart attack.

The relative risk reduction is 50%. That sounds spectacular.

The absolute risk reduction is one percentage point: the event rate fell from 2% to 1%.

Both statements are mathematically correct. They create very different impressions.

To prevent one heart attack under those circumstances, 100 people would need to take the drug for the specified duration of the trial (say 5 years). That is the number needed to treat, or NNT.

This distinction is crucial because researchers, pharmaceutical companies and news releases frequently feature relative risk reduction. Patients may hear that a drug cuts heart attacks by 25%, 40% or even 50% and assume that the medicine protects that proportion of everyone who takes it. We suspect that many healthcare professionals make that assumption.

It does not!

A 50% reduction could be interpreted as a decline from 50 events to 25 events per 100 people. That would be an enormous benefit and deserve headlines promoting the drug.

It could also represent a decline from 2 events to 1 event per 10,000 people. That would still be a 50% relative reduction, but 9,998 of every 10,000 people would have the same outcome whether they took the medicine or not.

David Diamond and Paul Leaverton reviewed this problem in the journal Cureus. They are number crunchers and they argue that emphasizing relative risk while minimizing absolute risk can cause both clinicians and patients to overestimate the benefits of cholesterol-lowering treatment.

Their article is available here (Cureus, May 1, 2023). In my humble opinion, it is extremely well written. You can download it and provide it to your healthcare professional.

The authors are outspoken critics of conventional cholesterol messaging, and not every cardiologist accepts all their interpretations. Nevertheless, the arithmetic behind relative and absolute risk is not controversial. Patients should be shown both.

How Much Longer Do People Live on Statins?

Another way to describe benefit is to ask whether a medicine postpones death and, if so, for how long. This is actually easier for most people to understand than relative vs. absolute risk reduction.

Researchers writing in BMJ Open over a decade ago analyzed randomized statin trials and calculated the average postponement of death during the duration of each study. In primary-prevention trials, the median postponement was 3.2 days. In secondary-prevention trials, it was 4.1 days.

Here is how the authors summarize their findings:

“To the best of our knowledge, statin trials have not previously been subjected to a systematic assessment of survival gain by this technique. The survival gains we found are surprisingly small. The highest value was 27 days, found in the 4S study, achieved by 5.8 years of simvastatin therapy in participants with a history of unstable angina or myocardial infarction. Experience from studies of preferences, when presented with similar scenarios, shows that as many as 70% of lay persons would not accept such a treatment.”

That sounds almost unbelievable. Physicians we have asked guessed that statins extend life by many, many years.

These findings require an important qualification. The analysis measured postponement of death only during the trials, which generally lasted a few years. It does not tell us what might happen over an entire lifetime, and longer follow-up of some statin trials suggests that benefits can persist after the original study ends.

Nevertheless, these numbers challenge the widespread assumption that taking a statin for five years automatically adds years to everyone’s life. During the trials themselves, the average survival difference was generally measured in days rather than years.

That information becomes especially relevant for an older patient with limited life expectancy or for someone experiencing debilitating side effects.

More Support for the Days, Not Years, Life Extension

In case the article in BMJ Open from 2015 is not convincing to your healthcare professional, here are two more analyses.

This article was published in the Journal of General Internal Medicine in Aug. 2019 by Danish researchers. Here is the title:

“Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials”

The authors introduce their study this way:

“One challenge in the practice of medicine lies in adequately explaining the effects of a proposed intervention to enable a patient to make an informed decision. With regard to preventive interventions, such as statin use, effect size is traditionally expressed as relative/absolute risk reductions or ‘number needed to treat’ (NNT). However, such measures are not necessarily best for conveying intervention effect.”

“Here, we investigated the effects of statin treatment on postponement of death and performed a meta-analysis. We found that statin treatment resulted in a small average increase of survival within the trials’ duration. Meta-analysis of 16 large RCTs revealed a survival gain of 12.6 days within the trial duration. We stratified on prevention type and demonstrated the largest postponement among the trials with secondary prevention, 17 days compared to 10 and 9 days in the primary and mixed prevention groups.”

“We examined the effect of trial duration on postponement and found a much larger postponement among the trials with a trial duration of 5 years and above, compared to below 5 years (19 days vs. 6 days).”

In 2021 (Basic & Clinical Pharmacology & Toxicology) some of the same Danish researchers looked specifically at:

“Postponement of cardiovascular outcomes by statin use: A systematic review and meta-analysis of randomized clinical trials”

Results:

“We included 19 trials. The summary outcome postponements for the 15 cardiovascular outcomes varied between -1 and 38 days. For four major outcomes, the summary outcome postponement in days was as follows: cardiovascular mortality, 9.27 days; non-vascular and non-cardiovascular mortality, 1.5 days; any myocardial infarction [heart attack] 18.0 days; and any stroke, 6.1 days.”

Conclusion:

“Statin treatment provided a small, average postponement of cardiovascular outcomes during trial duration.”

Heart Attacks and Strokes

Preventing a nonfatal heart attack or stroke can be extremely valuable even if a clinical trial does not demonstrate longer life. No one should dismiss such outcomes.

But here, too, patients need absolute numbers. A 2024 analysis in the American Journal of Cardiovascular Drugs (November, 2024) examined intensive versus less-intensive lipid lowering:

“Time Gained to Cardiovascular Disease by Intensive Lipid-Lowering Therapy: Results of Individual Placebo-Controlled Trials and Pooled Effects”

The Dutch investigators calculated not only whether cardiovascular events were prevented, but also how long they were postponed.

After five years of intensive treatment, approximately 2 out of 100 patients avoided a major cardiovascular event. Among the entire group, the average postponement of such an event was approximately three to four weeks.

The authors summarized their results:

“This study aimed to compare the effectiveness of intensive versus standard cholesterol-lowering medications for heart disease and stroke benefits. Unlike previous research, this study focused on the absolute difference in risk and the average delay of heart attacks and strokes associated with these treatments. This study analysed data from 11 clinical trials involving over 100,000 participants. It found that intensive cholesterol-lowering medications for 2 or 5 years had a very small impact on heart attacks and strokes and did not lead to fewer deaths or longer lives. The biggest benefit seen was that overall heart disease and strokes did not happen in two out of every 100 patients, and it was delayed by about 3–4 weeks after 5 years of intense treatment. Given the modest effect found in this study, patients should think carefully about this information when making treatment decisions with their doctors.”

Conclusion:

“Given the small effect, patients should receive this information as part of shared decision making.”

Again, that does not mean preventing two major cardiovascular events is unimportant. To the two people who avoid a heart attack or stroke during the study period, the benefit may be enormous..

But the other 98 people also deserve to know that they did not receive that particular benefit during the study period.

Did you notice something interesting? The studies that examined “postponement of death” or bad cardiovascular outcomes were conducted by researchers in Denmark and the Netherlands. It would seem that such research and analysis is not encouraged in the United States.

Do Newer Cholesterol Drugs Do Better?

Statins are no longer the only powerful LDL-lowering drugs. PCSK9 inhibitors such as evolocumab (Repatha) and alirocumab (Praluent) can lower LDL dramatically. The newly approved oral PCSK9 inhibitor enlicitide, sold as Lipfendra, also produces striking reductions in LDL cholesterol.

The FOURIER trial tested Repatha in high-risk patients who already had cardiovascular disease. LDL cholesterol fell by an impressive 59%.

The relative reduction in cardiovascular death, heart attack or stroke was reported as 20%.

The absolute difference was considerably less dramatic. Such events occurred in 7.4% of placebo patients and 5.9% of those receiving Repatha. That is an absolute risk reduction of 1.5 percentage points over a median follow-up of 2.2 years.

Put another way, approximately 67 high-risk patients would have to be treated during that period to prevent one such composite cardiovascular event.

There was no significant reduction in cardiovascular death or death from all causes during the original trial. The overall benefit was driven primarily by fewer heart attacks, with a smaller reduction in strokes.

The FOURIER study is available at this link.

Bempedoic acid (Nexletol) has been studied in people who could not or would not take statins. In the CLEAR Outcomes trial, the primary composite cardiovascular outcome occurred in 13.3% of placebo patients and 11.7% of those receiving bempedoic acid (New England Journal of Medicine, April 13, 2023).

What, you may ask, was the composite cardiovascular outcome?

“The primary end point was a four-component composite of major adverse cardiovascular events, defined as death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization.”

That represents a relative risk reduction of about 13%, but an absolute difference of approximately 1.6 percentage points. Roughly 63 people would need to be treated for about three and a half years to prevent one primary composite event.

There was no significant reduction in death from cardiovascular causes or death from any cause.

The CLEAR Outcomes trial is available at this link.

These medicines can be worthwhile for the right patients. Someone with established cardiovascular disease, familial hypercholesterolemia or very high risk may reasonably conclude that even a modest absolute reduction is worth pursuing.

That decision looks different for a healthy younger person whose chance of a cardiovascular event is already quite low.

An Inconvenient Question

This year the American Heart Association offered its most recent statistics on heart disease and stroke (Circulation, Jan. 21, 2026; JACC, Jan. 12, 2026). Over 900,000 people died from cardiovascular disease (CVD). We were told that CVD is still the No. 1 killer of Americans.

The Centers for Disease Control and Prevention (CDC) report:

“Heart disease has been the leading cause of death in the United States since 1921, and stroke has been the third leading cause since 1938.”

So, after more than 100 years cardiovascular disease remains the #1 killer in America. Cardiologists have been lowering cholesterol since the 1960s with a variety of medications. Mevacor (lovastatin) was the first statin approved by the FDA. It got the green light in 1987. That will mean that statins have been around for almost 40 years. And they work extremely well to lower LDL cholesterol.

Why, then, is heart disease still our number one killer? 

Should Statins for Almost Everyone Become the Rule?

We are not suggesting that people throw their atorvastatin or rosuvastatin into the trash. Stopping a statin abruptly without consulting the prescriber could be dangerous, especially after a heart attack, stroke, stent or bypass operation. No one should ever stop any prescribed medication without a thoughtful conversation with a physician!

Nor are we arguing that LDL cholesterol is irrelevant. Elevated LDL contributes to atherosclerosis, and lowering it can reduce cardiovascular events.

We are arguing for transparency. Before someone agrees to take a cholesterol-lowering drug for the next 20, 30 or 40 years, the clinician should answer several straightforward questions:

• What is my absolute risk of having a heart attack or stroke?
• How much is this medicine expected to lower that absolute risk?
• How many people like me must be treated to prevent one event?
• Has the drug been shown to help people live longer?
• How much longer are people like me likely to live if they take this medicine?
• What side effects should I watch for?
• Would a coronary artery calcium scan or another test help clarify whether I am likely to benefit?

And what happens if diet, exercise, weight control, adequate sleep, blood-pressure treatment and smoking cessation are given serious attention first?

A coronary artery calcium score may be especially useful when a person falls into a borderline or intermediate category. Evidence of plaque could strengthen the argument for medication. A score of zero might support postponing treatment in some people, although age, diabetes, smoking and family history still matter.

The People’s Pharmacy Bottom Line

The new cholesterol guidelines make approximately 87.5 million American adults eligible for statin therapy to prevent a first cardiovascular event. More than 93% of people in their seventies qualify under the new guideline.

That comes remarkably close to statins for almost everyone, at least once Americans reach retirement age.

Statins and newer cholesterol-lowering drugs can prevent heart attacks and strokes. The benefits are most compelling for people at high risk or those who already have cardiovascular disease. For lower-risk people, however, relative-risk headlines may make the benefit appear much larger than it is. Absolute risk reduction, number needed to treat and the likelihood of living longer should be part of every conversation.

Patients should not have to choose between breathless enthusiasm and outright statin rejection. They deserve accurate numbers, presented in a way that ordinary human beings can understand.

We have not delved into statin side effects in this article. You can find a People’s Pharmacy analysis at this link.

Final Words

What has been your experience with statins? Do you tolerate them without difficulty? Have you experienced muscle pain, weakness, elevated blood sugar or other problems? Please share your story in the comment section below.

This overview cites a lot of research that may conflict with what your healthcare provider believes. We would like to encourage you to print some of these studies and offer them to your prescriber the next time you get together. In particular, we think this article in Cureus (May 1, 2023) is excellent. That’s because the authors do such a good job explaining the difference between relative risk and absolute risk reduction.

We have tried our best to provide you with a deep dive into cholesterol-lowering drugs in general and statins in particular. If you found this article understandable, please share your thoughts in the comment section below. We would also be very grateful if you would be kind enough to share it with family, friends and acquaintances. Should you like to learn more about some other options for improving outcomes, here is a link to our eGuide to Cholesterol Control & Heart Health. It can be found under the Health eGuides tab.

The concepts of absolute risk reduction and number needed to treat are challenging, but we think they are incredibly important when discussing a new drug treatment with a healthcare provider. We hope we have given you some tools to make that job a bit easier. If you agree, we would hope you will encourage your network to subscribe to our free newsletter at this link. That will enable us to keep providing these sorts of in-depth analyses.

If you can afford $5 a month, you can go ad-free. That way the articles you read on this website will not be interrupted by ads every couple of paragraphs. Here is a link to the ad-free experience. If you don’t care about the ads, but would like to donate to our work, here is a link to support our mission. Thank you for your support.