An average atherosclerotic plaque in a coronary artery is about three millimetres across and takes roughly forty years to develop. For the mainstream story to hold, that plaque has to be built one LDL molecule at a time, which works out at 3.5 quadrillion molecules passing through the artery wall over 15,000 days. One molecule, through one endothelial cell, every three or four seconds, for four decades. Dr Malcolm Kendrick’s The Clot Thickens: The enduring mystery of heart disease (2021) is built around the observation that this cannot happen as described, and the conclusion that plaques are something else entirely: the remnants of blood clots. Fibrin, the protein that binds every clot together, is found in all plaques, at every stage of their development, and even in otherwise healthy artery walls. Fibrin in a healthy artery wall, Kendrick writes, is like bones in the ground. All that remains of the dead body after the rest has rotted away.
Kendrick is a Scottish general practitioner who has spent more than thirty years investigating what actually causes cardiovascular disease. He is a member of The International Network of Cholesterol Sceptics (THINCS), the loose confederation founded by Dr Uffe Ravnskov, whose 1991 book The Cholesterol Myths was burned on live television in Finland. His earlier books, The Great Cholesterol Con (2007) and A Statin Nation (2017), argued the negative case against the cholesterol hypothesis. This book presents the positive case for the alternative. His turning point came at a cardiovascular conference, when Professor Paul Rosch (chairman of the American Institute of Stress) told him over dinner to stop looking for a single cause and start studying the process. The medical journalist Jerome Burne has described Kendrick as “effectively medically excommunicated” for his pains.
When the book appeared in 2021, the diet-heart hypothesis had been the governing framework of cardiovascular medicine for roughly seventy years. Ancel Keys first proposed it in 1948. The 1977 McGovern Dietary Committee enshrined it as policy for 220 million Americans and 56 million Britons. A BMJ systematic review of the evidence available to that committee found no randomised controlled trial support, then or since, for the dietary guidelines it issued. The Minnesota Coronary Experiment, a 9,000-participant RCT running from 1968 to 1973, produced results that contradicted the hypothesis so sharply (a 22% higher risk of death for each 30 mg/dL reduction in serum cholesterol) that the data sat unpublished in a dusty basement for forty-three years, until Christopher Ramsden of the NIH recovered the punch cards and brought them out in 2016. By then, statins had become the most prescribed drug class in history. Dr Kilmer McCully was pushed out of Harvard for pursuing homocysteine research instead. Dr George Mann, who helped set up the original Framingham study, was written out of its history after breaking ranks.
A thin line of dissent runs from Karl von Rokitansky, who proposed the thrombogenic model in 1852, through Virchow who accepted part of it, through Mann and Ravnskov and McCully to THINCS and this book. The full summary unpacks three findings that collapse the cholesterol consensus from inside its own evidence base: the Nord-Trøndelag HUNT2 study of 50,000 Norwegians, which found a 40% mortality reduction for women with the highest cholesterol levels; the glycocalyx, a protective layer of glycoproteins and nitric oxide covering every endothelial cell, which Kendrick estimates 99.8% of doctors have never heard of; and the physical mechanism by which fibrin, platelets, and endothelial damage combine to produce the plaques that medicine has spent seven decades blaming on fat intake. The Minnesota data were in the basement for forty-three years. The glycocalyx has been in the literature for longer. Rokitansky proposed the explanation when Victoria was on the throne.
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