Your GP prescribes on the wrong number.

Monday named the cholesterol number your standard panel skips. Today names the pill your GP has probably been trained to prescribe on the wrong evidence.

Statins save lives. The trial data is unambiguous in the population where they belong: adults with established cardiovascular disease, familial hypercholesterolemia, elevated Lp(a) plus elevated ApoB, or a genuinely high 10-year event risk. In that population the pill is a load-bearing intervention and the brand does not argue against it. The problem this piece names is different. In the low-risk primary-prevention population, the numbers your GP is quoting when the prescription pad comes out are relative-risk numbers. The absolute numbers, the ones that should decide whether you take a daily pill for the rest of your life, are much smaller. Many of those prescriptions should not be written.

The single most-cited body of evidence is the Cholesterol Treatment Trialists' Collaboration meta-analysis in the Lancet, pooling individual data from 27 randomised trials and 175,000 participants. The headline: each 1.0 mmol/L reduction in LDL-C from statin therapy prevents roughly 11 major vascular events per 1,000 patients treated over 5 years. Relative risk reduction of about a quarter. That is the number the drug reps and the guideline documents lead with, and it is real.

The absolute number tells a much smaller story in the low-risk population. If your five-year risk of a cardiovascular event is 5 percent to begin with, a 25 percent relative reduction moves it to roughly 3.75 percent. You have prevented one and a quarter events per 100 people treated for five years, which is an NNT of roughly 80. If your five-year risk is 2 percent, the arithmetic gets worse. The Byrne et al analysis in the British Journal of General Practice ran this calculation across the recommended treatment thresholds and found the NNTs at the low end regularly cross into the range where roughly half of patients say they would not choose to take a daily pill for the tradeoff.

The number that should drive the conversation is not LDL-C. It is your absolute ten-year risk, adjusted by whether ApoB and Lp(a) push you higher than the standard calculator suggests. Most GPs have not been trained to reweight the calculator by ApoB and Lp(a), because the panels they order do not include them. The prescription gets written on an incomplete number.

The strongest defence of aggressive statin prescribing is not about the individual patient. It is about the population. If you put a million adults with elevated LDL on a statin, the CTT meta-analysis says you prevent tens of thousands of events at the population level, and the side-effect burden is small in the trials. That is real. Public-health statins have saved a lot of lives.

Two answers. First, the population-level argument does not tell any individual patient what they should do, because the individual patient's absolute risk depends on their specific numbers, including the ones the standard panel does not measure. The right patient-facing move is to know your risk before you agree to daily medication, not to accept a prescription written on a relative-risk headline. Second, the trials that produced the meta-analysis were run predominantly in higher-risk populations. Extrapolating those results down into the truly low-risk primary-prevention band is where the ethics and the arithmetic both get thinner. Nobody is arguing against statins for the patient with a heart attack in their history. The brand is arguing that the prescription pad should stop at the ApoB and Lp(a) numbers, not before them.

Before you accept or decline a statin for primary prevention, do two things.

First, calculate your actual ten-year absolute risk. The ACC/AHA ASCVD Risk Estimator Plus is free and gives you the number your GP is (or should be) using to make the recommendation. Below roughly 7.5 percent ten-year risk, most current guidelines do not recommend a statin. Above 20 percent, most do. The middle band is the negotiation.

Second, ask for the panel that reweights the number. ApoB is the count of atherogenic particles, the input that actually drives risk. Lp(a) is the genetic layer we covered Monday. hs-CRP is the residual inflammatory risk marker. All three change the ASCVD calculation. Australian’s can order an i-Screen's advanced lipid panel bundles ApoB and Lp(a) for roughly $180 in Australia. American’s can access an advanced Lipid Panel via Ultalabs for under $150, while Function Health covers all three in its US annual panel. Book the advanced draw before you say yes to the pill.

For the longer read on the framework, Peter Attia's Outlive spends four chapters on the ApoB-driven case for early aggressive lipid management in the right patients and the case against blanket primary-prevention prescribing in low-risk adults. It is the single best consumer treatment of the argument this piece is compressing.

Three markers, one blood draw. Lp(a) from Monday. ApoB from today. hs-CRP as the inflammation input that closes the risk picture. The three numbers to ask for by name at your next blood test, why the standard panel does not include them, and how to interpret each. Friday.

Longevity Daily · The Building Decades

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P.S. Run the ASCVD calculator before you close this email. If you are under 7.5 percent, the conversation with your GP starts differently.

Sources: CTT Collaboration, Lancet 2012 · Byrne et al, BJGP 2019 · 2026 ACC/AHA Dyslipidemia Guideline

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