Statins and CVD

https://www.sciencedirect.com/science/article/pii/S2213858719303882#fig1


This meta-analysis is indeed a study about interventional clinical trials with drugs (Statins or Statins and Ezetimibe vs no drug) in patients with CVD and the endpoints are clinical events but not death either CV deaths or all deaths.
The issue is that the biomarker control of drug efficiency is not the drug concentration, nor the volume of plaques all over the arterial tree and nor the flow of LDL particles in plaques; it is a fraction of lipid particles in the circulating blood identified by the cholesterol content of those LDL particles. Nothing new indeed.
Statins act as anti-inflammatory drugs for the arterial plaques. They reduce the number of plaque ruptures which occur spontaneously or under stress conditions like surgery, exercise or other circumstances. And it is interesting to observe that the maximum RR effect is in symptomatic patients and especially during the months or 1-2 years following the ischemic event (cf Stroke and statins, 10.1056/NEJMe1914757). This is not according to my point of view a "proof" of the lipid-heart hypothesis. But it is a strong back to use statins in symptomatic patients for a limited time if they succeed after the event to manage their risk factors.