The answer to that question is complex and individual and before thinking about that you should have a basic understanding of cholesterol in your body. You can learn about this from my video and blog post
Statins
In the previous episode, I talked about Cholesterol in your body. This week as a follow up I’m talking about Statins, a group of drugs that lower the level of cholesterol in the body. They work by acting on the liver’s mechanism for producing cholesterol inhibiting the enzyme Hydroxy-methylglutaryl-coenzyme A reductase (HMG-CoA reductase).
The Human Circulatory System
We know that cholesterol is closely linked to atherosclerosis – the formation of plaques that build up on the walls of our arteries and contain cholesterol and that these plaques can rupture or break off and cause blockages that cause cardiovascular disease that ranges from the mild decrease in blood flow to our limbs to the severe effects that throw blood clots into our brains and heart causing strokes or heart attacks. But as we learned last time – cholesterol is not all bad – it is an essential part of our body systems making up parts of cell membranes and integral to several signaling molecules.
Statins are also known to have additional effects beyond the simple reduction in cholesterol levels and production in our body and several studies have shown that these drugs also reduce inflammation in the cell walls which is not connected to the cholesterol-lowing effect. In fact, this effect occurs rapidly and is seen as soon as 2 weeks after starting statin therapy
Statins Drugs
Medication choices
There are multiple Statins around the oldest and best known is Atorvastatin (widely known by its brand name Lipitor) with its breakout general usage in 1996. The good news is this drug is off patent and there are plenty of low-cost generic options available and there is lots of safety data gathered given it has been in widespread use for over 20 years.
But Statins are not side-effect free and some find themselves suffering from constipation, diarrhea, and fatigue and in some 5-10% of people muscle cramps that can make the drug intolerable. This can be mitigated with some of the newer variant drugs that can help mitigate or even completely reduce the muscle cramps and other side effects. There is a rare and significant effect of causing diabetes in a small percentage of patient’s which is an important factor to consider when considering if Statins are right for you.
New Research on Statin Therapy
There has been lots of research and trials and the most recent I mentioned in the video the HOPE-3 trial which had a multifactorial design – meaning multiple variations on treatment therapies were tested in different populations.
They had a diverse group of patients divided up into multiple groups in a 2×2 factorial design that had groups being treated with a statin, an Angiotensin-converting enzyme (ACE) inhibitor for blood pressure and a diuretic hydrochlorothiazide also for blood pressure (BP). They had 12,000 people with a follow up to 5 years and they maintained good adherence for drugs of around 75%.
Overall, the anti-hypertensives did not reduce the risk of cardiovascular events at all – but there were differences depending on whether or not you had hypertension when you entered the trial. Interestingly the combined statin with an antihypertensive treatment was no better than a statin alone. And the data offered a clear benefit for Statins for those at intermediate risk of cardiovascular disease.
The details of this are nicely summarized here and the article includes links to the 3 published studies that were published from the data. One of the specific questions answered by this study is on that one cardiologist friend of mine and I have discussed before – should Statins be placed in the drinking water like fluoride. Given the cost and the side effects associated with statins, the answer is no for economic reasons as well as increased risk of side effects.
In the intervening time since I recorded this video another paper was published:
Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease: A Modeling Study, and a new set of guidelines from the American College of Cardiology (ACA)/American Heart Association (AHA) on the management of cholesterol in the blood: 2018 ACC/AHA Multi society Guideline on the Management of Blood Cholesterol
Which emphasizes a heart-healthy lifestyle but then details some very specific “high-intensity” statins to focus on specific cholesterol levels in people who are at high risk or with proven clinical cardiovascular disease (they reference ASCVD or atherosclerotic cardiovascular disease) alongside detailed clinical guidelines for stating therapy based on specific risk and disease assessments in individuals. There are too many variations to make any generalization beyond what I stated in the video – start with the incremental step of knowing your numbers and the details of your family history and medical history as contributing factors to your risk assessment to take with you and discuss with your doctor to decide what’s right for you
Once you have your numbers you should calculate your 10-year risk of heart disease or stroke using the Atherosclerotic Cardiovascular Disease (ASCVD) algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. This is available from several sources including this from MDCalc or this one which includes a spreadsheet you can download to plug in your values as well.
To include the new updated guidelines from 2017 and the ASCVD Risk Estimator Plus tool (background available here) you can download the app with updated guidelines from 2017 for Apple iOS but Android is a little more challenging with a generalized cardiology app which does not get as good reviews.
Ultimately the decision is a very personal one and is driven by data and supported by clinical evidence. There are no quick global answers, but it is an important decision for everyone to consider, especially if you have any contributing factors in your family history, past medical history or are suffering from any aspects of cardiovascular disease.
Listen in to hear the details Statin Therapy and if its right for you
Incremental steps – Deciding on a Statin
- Measure your Blood Cholesterol
Gather the details of your medical history
Use the ASCVD calculator to give you a guide based on the clinical research
Bring everything to your doctor and discuss the evidence data and make a personalized decision together
The evidence is clear for those in the groups that have treatment with a statin recommended that the benefits outweigh the risks and side effects.
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