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Sunday, September 25, 2022

Considering Statins? What a Cardiologist Wants You to Know

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About 35 million people take statins in the United States, but research says only 55% of those who are recommended to take a statin are taking one. This is a big problem because research also shows those at high risk who are not taking a statin have more preventable heart attacks and strokes.

Many people who would benefit from taking a statin don’t because they are concerned about the side effects. But does the risk of side effects really outweigh the benefits?

What are statins?

Statins is the short name for cholesterol-lowering medications called HMG-CoA reductase inhibitors. They are called statins because each one of these medication’s name ends with “-statin” (such as atorvastatin, rosuvastatin, simvastatin, etc.)

Statin medications are among the most prescribed drugs in the world. They are also among the most controversial.

Even if you don’t take a statin, you have likely heard or read about the side effects. You may have heard that they cause liver failure, lead to memory problems, and a life-threatening breakdown of muscles called rhabdomyolysis.

And there is an element of truth to this, but the reality is quite different than you may have been led to believe.

The first step in deciding if statins are right for you is understanding the risks and benefits.

What are the benefits of statins?

This is a critically important point to understand if you are considering taking a statin. Statins are among the most prescribed medications because they have a mountain of evidence that they lower the risk of heart attack, stroke, and death in those at high risk for heart disease.

Statins may be the most studied medicine in medical history, with more than 40 trials where statins were compared to placebo and shown to lower the risk of heart attack, stroke, and death in a high-risk group. Among medical experts, there is little debate these days on whether statins work in high-risk patients. The debate more commonly is how do we define high-risk.

In the statin risk vs. benefits discussion I commonly have with my patients, the benefits are clear. In almost all high-risk populations (exceptions are those with kidney failure on dialysis or symptomatic heart failure) studied, those who took statins had 20%-40% fewer heart attacks, strokes, and deaths over 2-5 years than those who took the placebo.

What are the risks of statins?

Like all medications, statins can cause side effects. In most research trials (and my clinical experience), side effects occur in about 10% of people taking a statin.

Worrisome side effects such as liver inflammation (there has not been a reported case of liver failure due to statins) and life-threatening muscle breakdown are exceedingly rare. In my 25 years of being a physician, prescribing statins for tens of thousands of patients, severe liver test abnormalities or muscle damage has occurred in less than five patients. 

Far and away, the most common side effect of statins is muscle aching, also called myalgia. But whether this is due to the medication or the impact of our mind’s negative expectations (called the “nocebo effect”) is controversial. Some studies have shown that side effects are about the same when a placebo is compared to statins. And based on this, some physicians feel that our minds and not our bodies cause statin muscle aches.

Maybe this is right, but I have a different perspective for two reasons.

  1. I’ve had a lot of experience with people who have side effects from statins. When I worked at the Mayo Clinic, I (half) jokingly said I saw everyone in the system who couldn’t take a statin. I met many people who were desperate to take a statin because they believed the benefits but could not tolerate the side effects.
  2. I also have muscle aching side effects to statins.

It’s possible for my patients and me, the problem is the “nocebo effect,” but discounting the symptoms isn’t helpful and doesn’t make it any less real.

What if you have had statin side effects?

Ninety percent or more of people can take a statin with no side effects. But if you’re not one of them, here are three essential points to emphasize:

  1. Recognize our mind is powerful and the nocebo effect is real. If you’re unsure whether your symptoms are indeed from the statin or not, work with your doctor to see if you can find a regimen that works for you.
  2. Just because you’ve had side effects on one statin doesn’t mean others won’t work for you. Different statins, dosages, or alternative schedules can be effective. Under a doctor’s supervision, statins are almost always safe.
  3. Ask your doctor if other cholesterol medications are an option. Both ezetimibe and the PCSK9 antibody medications have been shown to lower the risk of heart attack and stroke.

If you’re undecided about taking a statin, you’re not alone. The decision to take a statin or not is complex and best made with a discussion between you and your doctor. Be sure and ask about the risks compared to the benefits and also if there are alternatives that would make sense for you.



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