Thread by @drShaileshSingh

Many people believe statins are a product of marketing.

In reality - its neither a miracle, nor marketing, its "medicine."

here is a detailed explanation for people who are miisinformed, a good read for doctors who havent properly read the studies.
read on⤵️

1️⃣ Not all statin trials are the same
The tweet lumps together very different studies.

REVERSAL enrolled just 502 patients with coronary artery disease and measured change in atheroma volume by intravascular ultrasound.

A high‑dose atorvastatin regimen halted plaque growth whereas pravastatin allowed plaque progression.

This was a mechanistic study with a morphological end‑point, not a huge trial with multiple chances to “spin” results.

KEY MESSAGE:
Among patients with symptomatic CAD and elevated LDL, use of an aggressive lipid-lowering strategy through treatment with 80 mg atorvastatin was associated with a reduction in the primary endpoint of percent change in atheroma volume compared with a more moderate lipid-lowering strategy through treatment with 40 mg pravastatin.
acc.org/Latest-in-Card…

ASTEROID was an open‑label study of intensive rosuvastatin in 507 patients.

LDL‑cholesterol fell from 130 mg/dL to 61 mg/dL and plaque volume regressed by 0.98%.

There was no control group.

lesson learnt from the trial:
Among patients with angiographic coronary disease, treatment with intensive statin therapy with rosuvastatin 40 mg was associated with atherosclerosis regression on IVUS at 2-year follow-up.
jamanetwork.com/journals/jama/…

PROVE‑IT TIMI‑22 was a properly randomised trial (n≈4,162) in patients hospitalised with acute coronary syndrome.

2 arms - standard lipid reduction vs aggressive lipid lowering using high intesnity atorvastatin

High‑intensity atorvastatin cut the composite endpoint (death, myocardial infarction, rehospitalisation, revascularisation or stroke) from 26.3 % to 22.4 % — a 3.9% point absolute reduction and a 16 % relative reduction.

The trial showed that more intensive statin therapy brings additional benefit.
nejm.org/doi/10.1056/NE…

JUPITER tested rosuvastatin in low‑risk men ≥50 years and women ≥60 years with normal LDL but elevated C‑reactive protein.

The composite cardiovascular event rate was 0.77 % per year with statin and 1.36 % with placebo —an absolute risk reduction of 0.59 % per year and a relative risk reduction of 44 %.

This difference is modest because participants were low‑risk, yet the relative risk reduction is substantial.
nejm.org/doi/full/10.10…

ahajournals.org/doi/10.1161/CI…

Why “multiple endpoints” and large samples?

Serious cardiovascular trials use composite endpoints (death, heart attack, stroke or revascularisation) because each individual event is uncommon.

Combining them improves statistical power and reflects the full burden of disease.

Large samples and long follow‑up are ethical necessities—small trials would not detect meaningful differences.

For example, PROVE‑IT’s sample of ~4 000 provided enough events to show that high‑intensity statins reduce clinical outcomes by 16 %.

REVERSAL and ASTEROID were small mechanistic studies, not marketing schemes.

A relative risk reduction tells us how much a treatment changes the rate of events compared with a control. Absolute risk reduction depends on the baseline risk.

In JUPITER, the relative risk reduction of 44% came from lowering annual event rates from 1.36 % to 0.77%.

The number needed to treat (NNT)—the number of people who must be treated for one year to prevent one event—is the inverse of the absolute risk reduction.

JUPITER’s NNT was ~169 per year for the composite endpoint, because participants were healthy.

By contrast, PROVE‑IT studied patients who had just survived a heart attack. The absolute risk reduction was 3.9 % over two years , giving an NNT around 26–30—nearly six times better.

In high‑risk secondary‑prevention populations (previous heart attack or stroke), meta‑analyses show that lowering LDL‑C by 1 mmol/L with statins reduces major vascular events by ~20%
doi.org/10.1001/jamaca…
doi.org/10.1016/s2213-…

For someone with a 20% 5 year risk of recurrence, high‑intensity statins reduce that risk to 13 % —an absolute reduction of seven percentage points.
pmc.ncbi.nlm.nih.gov/articles/PMC78…

In the elderly, relative risk reductions remain similar, so absolute benefits are larger because their baseline risk is higher.
lipid.org/lipid-spin/win…

Industry funding ≠ unreliable data

Pharmaceutical companies often sponsor trials because they have the resources to conduct them.

However, these studies are run by academic investigators, require ethics approval, have independent data‑safety monitoring boards and are published in peer‑reviewed journals.

Their findings have been confirmed by independent, non‑industry meta‑analyses.

The Cholesterol Treatment Trialists (CTT) collaboration analysed individual data from 27 randomised trials (over 134 000 participants). They reported that each 1 mmol/L reduction in LDL‑C lowers major vascular events by about 22 % regardless of age, sex or baseline risk. High‑intensity statins confer additional benefit (15 % extra relative risk reduction).
These analyses are independent of pharmaceutical funding and provide robust evidence for statins’ efficacy.
cttcollaboration.org

So pissed seeing this from a doctor.

For people with definitive indications - these medicines save lives, prevent them from landing on cath lab table in crashing state at 2 am.
But...