10 truths about statins and high cholesterol

How do doctors decide who is prescribed a statin?

In preventive cardiology, it’s up to us to help patients avoid suffering from a sudden, serious cardiovascular event, such as a heart attack or stroke, or a long, grueling ailment such as atherosclerosis (hardening of the arteries). We determine on an individual basis which patients have the greatest need and who would benefit most from taking statins. We weigh these benefits against the known risks for each patient before we consider prescribing the medication. 

Like all medications with risks and benefits, there are specific guidelines we follow to ensure that we prescribe statins only to people who really need them.

The American College of Cardiology and American Heart Association developed these rational guidelines in 2013 after carefully reviewing the decades of published studies about statins. First, we determine a patient’s overall risk of cardiac disease, taking into account their cholesterol levels as well as other risk factors such as blood pressure, smoking history, diabetes, age, and sex.

There are four general categories recommended to determine who is at high risk for a cardiovascular event, such as a heart attack or stroke.

The guidelines recommend statins for adults who:
We know that statins can be used to protect against more than heart attack – statins also protect against stroke in high-risk patients. A stroke is caused by blocked blood flow to the brain, and high cholesterol is one of the culprits for such blockages. In high-risk patients, statins have been shown to decrease the risk of stroke by decreasing patients’ cholesterol.

We may recommend statins for other people, even if they don’t fit in these categories. For example, if a close relative has suffered a heart attack and your own cholesterol levels are getting higher regardless of lifestyle improvements, we may recommend that you take a statin.

Importantly, we consider cholesterol treatment as one piece of the overall puzzle of lowering risk. For example, it does little good to lower a patient’s cholesterol with a statin but ignore his or her high blood pressure. A comprehensive approach to risk factor management, including lifestyle factors such as diet and exercise, is most effective. 

• Have clinical atherosclerotic cardiovascular disease (ASCVD), including those with a personal history of stroke, heart attack, or peripheral vascular disease, and also those who suffer from chest pains (angina)
• Have high cholesterol (an LDL cholesterol of 190mg/dL or higher)
• Are age 40 to 75 and have diabetes
• Are age 40 to 75 and have an estimated 10-year risk of an ASCVD event greater than 7.5 percent

Do statins cause muscle pain and weakness?

Muscle aches occur in about 10 percent of people who take statins. It’s the most common side effect of statins, but another way to look at it is that nine out of 10 patients don’t experience it at all.

When patients do have muscle pain:
Actual muscle damage occurs in only 1 in 10,000 patients. In the rare event that muscle damage occurs, it is almost always reversible. To correct it while still protecting you from heart attack or stroke, we can adjust your medication or try a different statin. There also are many strategies to effectively manage muscle symptoms while continuing to take your medication.

If you experience muscle pain while taking a statin, don’t stop taking it without first talking with your doctor. For almost all patients, we’re able to find an effective medication that the body can tolerate. If you simply can’t tolerate statins, there are other cholesterol medications we can prescribe.

• The symptom is often resolved by adjusting the medication dosage or switching to a different statin.
• Occasionally, the statins have to be stopped altogether.
• When the medication is switched or stopped, the symptoms go away and there is no damage to the muscle.

Can statins increase my risk for memory loss or dementia?

Memory and cognitive symptoms from statin use are very uncommon, and it is unclear if statins are really the culprit. When symptoms have been reported, they’re typically not severe and usually resolve when the statin dosage is adjusted or the medication is switched.

Affected patients have reported feeling unfocused or “fuzzy” in their thinking, but these experiences are rare. Concerns about long-term cognitive problems and memory loss due to use of statins have not been proven. On the contrary, most recent data actually point to potential prevention of dementia due to statin use.

These data are logical because one of the major causes of dementia is atherosclerosis, which is hardening of the arteries in the brain. There is strong evidence that statins protect against atherosclerosis. It’s one of the “invisible” benefits of taking a statin medication.

Also, keep in mind that increasingly high cholesterol (requiring treatment) and memory problems both are common symptoms of aging. Sometimes it’s difficult to disentangle these two, and that’s why statin use and memory problems may seem related at times.

If you’re concerned about statins and memory loss, don’t stop taking your medication without consulting your doctor. There may be other reasons for your memory symptoms, or alternate treatments for your high cholesterol can be considered.

Will statins increase my risk for diabetes or complicate my existing diabetes?

This risk is true to some extent, but it’s wildly exaggerated.

In fact, there are good data to show that people who have problems with their blood sugar or who have diabetes benefit most from statins. Even though their blood sugar may go up slightly, the added risk is significantly offset by the reduction in heart disease risk that a statin can provide.

If you’re already at risk for developing Type 2 diabetes, or if you have prediabetes, you may monitor your blood glucose more closely after starting a statin. But exercise and weight loss have been shown to lower the risk of developing diabetes in those with borderline blood glucose levels, regardless of statin use.

• If your blood sugar was under control before you began taking statins, your sugars may rise slightly. But if you’re slim, trim, and not predisposed to diabetes because of obesity, statins won’t cause you to develop diabetes.
• If you already had prediabetes or have borderline blood sugar levels, the statin may make your blood sugar rise enough to put you in the diabetes category. This happens to about one of every 255 patients taking statins. When it does happen, the patient is already on the path to getting diabetes – it just happens a little faster. In these patients, statin use simply accelerates by a few weeks to a few months a condition that was already inevitable over their lifetime.
• Statins slightly increase the incidence of Type 2 diabetes in people who have two or more symptoms of metabolic syndrome, but the benefits of statins for these patients generally far exceed the risk of elevated blood sugar.

Can statins damage my liver?

Liver damage from taking statins is extremely uncommon. We used to test patients for liver damage throughout the course of statin treatment, but because of the rarity of that potential side effect, the Food and Drug Administration (FDA) determined that regular monitoring of liver function tests is unnecessary for patients taking statins. Now, we check a patient’s liver enzymes before we begin statin therapy to ensure the liver is healthy before treatment begins, and we don’t put anyone through unnecessary testing during treatment, unless symptoms arise.

Interestingly, there is a statin study examining people who already had abnormal liver function tests and fatty liver. Roughly half of the participants took a statin medication, and the other half took a placebo. The people who took statins actually had improvements in their liver function compared to the placebo group and had a lower risk of cardiovascular events. People who have blood sugar issues, have insulin resistance, and are obese or have other risks for heart disease often have fatty liver and abnormal liver function tests. The study suggests that these people may need statins the most.

On the rare chance that symptoms of liver damage arise, we’ll definitely want to perform tests right away. Symptoms of liver damage include weakness and fatigue, loss of appetite, upper abdominal pain, dark-colored urine, or yellowing of the eyes or skin. Again, it’s very rare, but if you experience any of these symptoms while taking a statin medication, contact your doctor right away.

Do statins cause cancer?

There is no evidence to suggest that taking statins increases cancer risk. Several studies suggest possible benefits for patients who take statins and are currently fighting cancer; research is ongoing as to whether statins actually may help prevent cancer.

Why do doctors focus on my LDL cholesterol?

Some cholesterol is necessary for normal cell and body function. But too much cholesterol can lead to atherosclerosis (hardening of the arteries), which results in heart disease, heart attack, and stroke.

There are two types of cholesterol: high-density lipoprotein (HDL, or good cholesterol) and low-density lipoprotein (LDL, or bad cholesterol). The amount of each that circulates in your blood is added together to form your total cholesterol number. Thus, focus on total cholesterol can be confusing as it may be elevated due to high HDL cholesterol.

When your LDL cholesterol is above 130 it is considered borderline, while above 160 is considered high. Ideally, we would all have an LDL under 100 (or even closer to 70), but not everyone needs medications above this level.

We focus on the bad cholesterol because it is one of the main culprits responsible for blocking and hardening the arteries. A blocked artery can lead to a heart attack or stroke. Statin therapy helps control the bad cholesterol of patients who are at high risk for heart disease, stroke, and other serious cardiovascular events. In general, the lower your LDL levels, the better off you will be.

There’s a lot of science around how HDL cholesterol affects your risk for heart disease. But it’s the function – how well it works – that may be more important than how high its level is.

For example, people in a small village in Italy have very low HDL numbers (10 to 30mg/dL), and they have a longer life expectancy and very little heart disease. That’s because their HDL is like a factory – it shuttles cholesterol from the arteries to the liver rapidly, and then disappears. Good cholesterol doesn’t last in their blood very long, but it is very efficient.

Society’s focus on raising HDL is likely misguided when compared to the actual evidence. Two recent studies of raising HDL with niacin showed no improvement in risk of heart attacks and strokes, and potentially some harms. There is a lot of work to be done to determine what we can and should do in targeting HDL.

Can ‘natural’ remedies lower high cholesterol without statins?

Exercise on its own doesn’t lower your LDL (bad cholesterol) much – often only a few points. Exercise helps minimize many heart disease risk factors, including obesity and Type 2 diabetes. Make a point to exercise five days a week for at least 30 minutes each day.

Diet is incredibly important in managing your cholesterol.
Every patient who comes to our preventive cardiology clinic for cholesterol management sees a nutritionist as part of the visit because we feel so strongly about the importance of diet. There are many patients for whom we’ve delayed prescribing statins, or suggested that they get off their medication if it isn’t appropriate for their level of risk.

Some patients think, “I’m on a statin – I don’t have to exercise, and I can eat whatever I want!” But that’s not the case. Lifestyle choices absolutely matter. For high-risk patients, it’s not a question of either improving the diet or getting on a medication, it’s both – lifestyle changes and taking a statin together are necessary to protect high-risk patients against heart attack and stroke.

If your cholesterol is borderline but not yet high, changing your diet and incorporating healthier food choices can help lower your cholesterol a decent amount. Eating more fiber and lowering your intake of saturated fat definitely can help. For people with relatively low risk, this may be enough to lower heart attack and stroke risk. 

• Certain foods, such as fried food and fast food, are high in saturated fat, which contributes to high cholesterol.
• Not all fats are unhealthy – good fats, such as those found in fatty fish, nuts, and olive oil, have many health benefits.
• Read food labels and limit your daily intake of saturated fat to 16 grams, and omit trans fats completely.
• Eating more fiber can help reduce LDL significantly. For some patients, eating fiber along with maintaining an exercise program is enough to manage cholesterol. But for high-risk patients, it’s not enough to prevent the need for statins.

Are there alternatives to statins for lowering high cholesterol?

In patients whose cholesterol can’t be controlled by lifestyle changes or who simply can’t tolerate statins, we can offer alternative treatments.

Bile Acid Binding Resins

For example, the FDA has approved a class of drugs known as bile acid binding resins, which were the first cholesterol drugs before statins. Studies in the 1980s showed that these medications lower heart disease risk. One reason they aren’t often prescribed is that patients have to take a lot of them compared to statins. Bile acid binding resins come in powder form or require taking up to six pills a day. Also, they can cause gastrointestinal side effects.

We’ve known since the 1990s that statins benefit patients at high risk for stroke and heart disease. Today, several investigators are researching which complementary medications can be prescribed on top of statins to make them even more beneficial and protective.

One of these is a drug called Ezetimibe, which on its own provides a modest reduction in cholesterol. It’s also been shown recently to lower heart attack and stroke risk when taken in addition to a statin.

PCSK9 Inhibitors

There are other non-statin cholesterol medicines, too, but the same principles apply – they should be used only for high-risk patients, and the risks must be weighed against the benefits.

In 2015, the FDA approved two new drugs that target and inhibit the PCSK9 protein, which affects the levels of bad cholesterol. The two drugs, Repatha and Praluent, block or reduce PCSK9 activity in order to lower LDL cholesterol by more than 50 percent and potentially reduce cardiovascular risk. These drugs are not pills; they are taken via monthly or twice-monthly injections. Outcomes data for PCSK9-inhibiting drugs are not yet available, but we are looking forward to seeing those results within the next few years. Currently, these drugs are FDA approved for those with ASCVD or those with a genetic cholesterol problem called familial hypercholesterolemia whose cholesterol levels are not controlled enough by a statin.

Red Yeast Rice

Many patients also ask about red yeast rice.

It’s available over the counter, and it actually works to lower bad cholesterol. It’s important to understand that there is a small amount of statin in red yeast rice. If people take it to avoid statins, they’re really not avoiding statins at all. Ultimately, those at high risk should first try a statin. However, studies have shown that in those who cannot tolerate a statin, some people do have fewer muscle aches when they take red yeast rice instead.

Fish Oil

Some people take fish oil supplements to try to lower their LDL and triglycerides, but it doesn’t work very well. Fish oil will lower your triglycerides at high doses, but not your bad cholesterol by very much. It has even been shown to raise bad cholesterol in some studies.

Heart disease prevention services can benefit patients who need additional support to improve their cardiovascular health. Services such as cholesterol management and nutrition guidance, and advanced testing in some patients, can help with risk management, sometimes without the need for medications.

Remember: It’s not a good idea to stop taking your medication without first talking to your doctor. If you experience side effects, ask your doctor to help you find an alternative treatment option. For most patients, we’re able to adjust the dosage of a statin medication to eliminate side effects. There are many varieties of statins available, so if adjusting the dosage doesn’t work, we can try a different medication.

Get medical advice from your doctor – not the Internet

There is no reason to be afraid of taking statins if you are at high risk for heart attack or stroke. What’s really scary is the amount of inaccurate information out there that keeps so many people from getting the protection they need!

The risks and side effects associated with statins are real; they aren’t zero, but they’re very small. However, the benefits of statins for high-risk patients are substantial, and they’re invisible. Patients often don’t consider that they didn’t have a stroke or heart attack last year – they’re too busy living and enjoying their lives while the statin medication protects them behind the scenes.

Statins are not for everyone, and there are complementary ways to lower your risk for heart disease. But for high-risk patients, the benefits of statins far outweigh the risks, and statin medications have a very important role in protecting their hearts – and their lives. It’s vital that you get medical advice from a doctor instead of trusting potentially misleading information on the Internet.

All patients need to understand their personal risks and also know their numbers: cholesterol, blood pressure, weight, blood sugar, and waist circumference. These numbers are important in order to make an educated decision. Occasionally, advanced tests such as coronary calcium scans or blood tests can help when you are on the fence about treatment. Do not rely on information from neighbors, friends, or even family members; rather, take time to understand with your doctor your real risk for heart attack or stroke.

Though statins are incredibly effective, there are many different forms of heart disease. Heart disease is still the No. 1 killer of men and women in our country, and the epidemic is spreading throughout the world. As long as the battle continues, we’ll continue researching new ways to prevent and treat heart disease.