Heart disease continues to be the number one cause of death in the United States, despite the potential for its prevention. Atorvastatin, a lipid-lowering medication, is the number one prescribed medicine. If everyone were treated according to current guidelines of the American College of Cardiology and the American Hospital Association, nearly half of adults between the ages of 40 and 65 years of age would be taking a statin. These guidelines are based on studies of the impact of statins on lipoprotein levels risk of cardiac ischemic disease based on those levels. As a result, many cardiologists and other physicians (including some such as Peter Attia who specialize in longevity promotion and chronic disease prevention) recommend treating LDL to below 50 mg/dl.
This approach is based not only on population data, but also on the increasing understanding of the pathophysiology of coronary artery disease. Cardiac ischemia (inadequate oxygenation of heart muscle due to blockage of circulation in the coronary vessels) results from plaque in the vessel wall that follows passage through the surface (endothelial) layer of the artery of LDL particles that are then oxidized, attracting inflammation that bulges into the channel of the vessel. Cardia ischemic risk is therefore a result of the number of LDL particles, the potential for their oxidation, and the potential for inflammatory reaction. Statins and related medications reduce the number of LDL particles, and may have an anti-inflammatory effect.
Statins also have adverse effects on mitochondrial energy production, causing ferroptosis that disrupts membranes and reduces mitochondrial numbers, reduces CoQ 10 levels, and inhibits respiratory chain complexes. Their use is associated with increases in diabetes and dementia. As a result there is concern about whether benefits justify the risks, particularly if they are used in a broad cross-section of the population.
Another strategy for cardiac ischemic risk reduction is to evaluate the extent of plaque accumulation in coronary vessels and treat those with concerning plaque volume and type with medications. People at lower risk use dietary and antioxidant treatments, as well as other interventions to reduce inflammation. Cardiac plaque can be imaged with coronary computed tomographic angiography using specialized software that reveals plaque volume and whether the plaque is at an early stage (more likely to cause vessel obstruction) versus a later, calcified stage and potentially in need of aggressive medical treatment.