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Cholesterol and Heart Disease: What’s the Evidence?

Posted on 2nd July 2018 by

Evidence Reviews
heart with blood vessels visualising cholesterol

The idea that high cholesterol causes heart disease is so widespread you’d have thought it was pretty much an established fact by now. High cholesterol is listed as one of the five main risk factors for heart disease by the British Heart Foundation [1], and the NHS public guidelines on cholesterol claim that “your risk of developing coronary heart disease rises as your blood’s cholesterol level increases” [2]. In supermarkets, you’ll find a significant array of spreads, yoghurts and cereals which claim to improve your cholesterol levels and decrease your risk of heart disease.

But what actually is the evidence that having high cholesterol, or high LDL (low density lipoprotein) levels, increases your chance getting heart disease? You may be surprised to learn that the studies available to us do not all point towards a causal connection between high cholesterol and heart disease. Different studies point towards a number of conflicting conclusions, and ultimately the picture is a lot more complicated than most media on the topic would suggest.

The association between cholesterol and heart disease

At first glance, it seems that we have substantial reasons to believe that high cholesterol and heart disease are closely linked. For one thing, we have a plausible-sounding explanation as to why they should be. This explanation posits that LDLs are the ‘bad’ type of cholesterol, which can stick to the inner walls of your blood vessels and potentially clog them, leading to heart conditions such as stroke, atherosclerosis, angina and coronary heart disease (CHD). Whereas HDLs (high density lipoproteins), are the ‘good’ type of cholesterol, and these have the opposite effect. [3]

There are some reasons to suggest that this hypothesis is correct. Firstly, there is evidence of a correlation between high cholesterol/LDL levels and heart disease. The Framingham Study, a prospective cohort study beginning with over 5,000 participants, published a paper in 1977 which concluded that higher HDL levels and lower LDL levels were associated with a reduced risk of coronary heart disease. [4]

In addition to this, some medical treatments which reduce cholesterol/LDL levels also reduce your risk of heart disease. Statins, for example are effective in both lowering cholesterol levels, and reducing the rates of CHD, cardiovascular disease (CVD) and stroke. [5]

Conflicting evidence

This evidence seems to point towards there being a causal connection between cholesterol in heart disease. However, a closer examination of the issue may make us sceptical of this conclusion.

Firstly, the evidence about the association between high LDL levels and heart disease is more complicated than it first appears. A follow-up from the initial Framingham study suggested that there was only an increase in mortality, by heart disease or other causes, in people with higher cholesterol levels under the age of 50 [6]. This is significant if we want to offer medication or lifestyle advice about preventing heart disease to those over 50 years old. A recent systematic review even suggests that patients over the age of 60 actually lived longer if they had higher LDL levels, directly contradicting the hypothesis that you are more likely to die of heart disease the higher your cholesterol levels are. [7]

Moreover, despite statins showing a correlation between lowered cholesterol levels and a reduced risk of heart disease, some other medications do not show this connection. Niacin, for example, is a cholesterol lowering drug which is known to decrease LDL levels, but has been shown to cause no significant reduction in risk of heart attack, stroke or mortality by heart disease [8] . Even more worrying is the case of Torcetrapib. This experimental drug was designed to reduce rates of heart disease by lowering patients’ LDL levels, but the research was discontinued early because it was linked to an increased risk of mortality and heart disease [9].

A causal connection?

You might be wondering how we ended up at this point, with significant amounts of evidence about cholesterol and heart disease pointing in completely opposite directions. There’s no straightforward answer to why the evidence about this problem is so messy, but one thing that I think should give us pause for thought is exactly what we mean when we talk about ’causes’ in medicine.

In the case of risk factors like cholesterol, a ’cause’ does not mean that the presence of this risk factor will always and invariably lead to a certain pathology. This depends on a number of other factors, like age, co-morbidities, lifestyle, and possibly plain luck. What we are actually trying to establish here isn’t nearly as straightforward as claims like “the TB bacterium causes tuberculosis”. Instead we are looking at a complex array of inter-related mechanisms, all of which may or may not lead to someone becoming ill. And when we are unclear about exactly how these mechanisms work or how they relate to each other, making predictions about health outcomes will inevitably be difficult and confounded.

References (pdf)


Sasha Lawson-Frost

I'm a Philosophy Student at UCL. I'm currently doing some research the philosophy of Evidence-Based Healthcare (EBH), particularly looking at how EBH deals with issues relating to patient well-being. Twitter: @sashalfrost View more posts from Sasha

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No Comments on Cholesterol and Heart Disease: What’s the Evidence?

  • Harry

    There is more evidence that the ratio of triglycerides to HDL shows a higher risk of heart disease, not LDL. It also is a good indicator of insulin resistance. Divide the triglycerides by the HDL. It should be less than 2. The higher it is the higher the risks.

    22nd February 2024 at 2:30 am
    Reply to Harry
  • Paul

    Thanks, Emma!

    4th November 2023 at 5:22 pm
    Reply to Paul
  • Emma Carter

    Dear Paul. You can find the references via a hyperlink at the bottom of the page. I have just updated the formatting to make this clearer so thank you for your comment. Best wishes. Emma.

    3rd November 2023 at 12:33 pm
    Reply to Emma
  • Paul

    Am I missing something, or are the references no longer on the page?

    3rd November 2023 at 8:59 am
    Reply to Paul
  • Paul Winter

    Has anyone read the book : The Great Cholesterol Myth, Revised and Expanded: Why Lowering Your Cholesterol Won’t Prevent Heart Disease?

    28th June 2023 at 9:52 pm
    Reply to Paul
  • Gene

    How to work with a cardio dr that insist i take a statin. I have CHD, my latest lipid readings: ldl= 146, hdl=78, triglyceride=57, a1c 5.1. I have been on low/no carb way of eating over a year. I am 5ft 9in 180lbs with an active lifestyle, and 61y/o male. I am not sure how to convince or suggest, the dr check out more studies. He explained that the current protocol, suggest I be on a statin daily as well as aspirin.

    3rd May 2023 at 4:22 am
    Reply to Gene
  • Emma Carter

    Hi Bruce, thank you for the comment. This recent blog on Evidently Cochrane may be of interest to you: https://www.evidentlycochrane.net/are-statins-good-as-we-think/

    23rd March 2023 at 9:43 am
    Reply to Emma
  • Bruce Burger

    Is there an efficacy rate of statins lowering the the risk of death from heart attack or stroke?

    22nd March 2023 at 2:54 pm
    Reply to Bruce
  • Helen

    Is this the guy we are basing our evidence from?

    14th October 2022 at 3:04 am
    Reply to Helen
    • Emma Carter

      Thank you for your comment Helen. I have removed the final paragraph, with a link to the video which is also no longer available. The remainder of the blog is based on references other than that video so it would be great to have your comments on that. Thank you.

      14th October 2022 at 10:47 am
      Reply to Emma
  • Michael turner

    Hi Sasha, I have been diagnosed with high cholesterol levels and thought I better find out about the evidence. Your article came up and quoted HS public guidelines on cholesterol which claim that “your risk of developing coronary heart disease rises as your blood’s cholesterol level increases” [2]. reference 2 is a website which says very little and certainly does not say “your risk of developing coronary heart disease rises as your blood’s cholesterol level increases”. Would you be able to point me to a source that does say that?

    27th January 2022 at 4:36 am
    Reply to Michael
  • Gulam Dudhia

    All of my family members and friends who have died of heart diseases were on cholesterol and blood pressure lowering drugs. Not only they never got the benefit of long life but had to suffer the negative side effects over the years which reduced their quality of life.

    24th July 2021 at 12:37 pm
    Reply to Gulam
  • Lisa Manetti

    Thank you- I wish to know more about cholesterol as I “claim” to be at risk for heart attack because my cholesterol “bad” LDL is 420-

    19th August 2020 at 3:09 pm
    Reply to Lisa
  • Simon

    Hi Sasha,
    Thank you for the article on cholesterol and CVD and for the video link. I’m 71 with high LDL & Trigls, & low HDL and am in almost constant discussion with my Dr. on meds. I’ve already had a bad muscular fatigue reaction to statins so fenofibrate is now the suggested medication.

    My only suggestion for improvement of the article would be to have your paragraph discussing what we mean by “cause” at the top of the article.

    Kind Regards,
    Simon Mundy

    10th August 2020 at 2:24 am
    Reply to Simon
  • A.H.Brown

    What should one conclude from the fact that this article references footnotes which are not provided?

    6th August 2020 at 10:52 am
    Reply to A.H.Brown
    • Emma Carter

      You can find the references in the link at the bottom of the text – this is what the numbering refers to. Many thanks.

      6th August 2020 at 11:57 am
      Reply to Emma

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