“An ounce of prevention is worth a pound of cure.” For those of us who believe in the power of preventive medicine, this mantra is our driving philosophy. As a cardiologist, I know that statins – the medicines many take to reduce their cholesterol – play a large role in my efforts to prevent heart disease.
For some of my patients, statins can be a tough pill to swallow. They wonder: Why take a medicine with the potential for side effects, when you’re unlikely to feel any different – just so you may reduce some theoretical risk of a heart attack in the future?
Understanding how statins work and the real risk of side effects can help reduce some of the anxiety around this medication and guide your conversation with your doctor about whether a statin is right for you.
How do statins work?
The most well-known effect of a statin is to reduce the amount of cholesterol in your blood by changing the way some proteins work in your liver. By reducing the total “bad” cholesterol in your blood, the statin makes it less likely that cholesterol will form plaques – or blockages – in the blood vessels going to your heart and brain. This is the effect most people have heard about.
There is also a second lesser known, and much more important, effect of statins on your heart arteries. When plaques form in the arteries going to the heart, they are a mix of cholesterol, calcium and scar tissue. The mix of these components is what determines the “stability” of the plaque. The less stable the plaque, the more likely it is to cause a heart attack. Statins are thought to affect the balance of cholesterol and scar tissue in the plaque, making it more stable and therefore less likely to cause a heart attack. Remarkably, this effect occurs at all cholesterol levels – which means even if your cholesterol is nearly normal, statins could still protect you.
As with all medications, the amount that an individual will benefit from using a statin will vary. But on the whole, statins have been shown to help reduce the risk of heart attacks and the complications of heart disease pretty significantly. In fact, in a recent review of 19 clinical trials that examined how helpful statins were in preventing cardiovascular events in people who had never had an event before, statins were associated with a 31 percent reduction in the risk of dying from a cardiac event and a 36 percent reduction in risk of having a heart attack.
To put that in perspective, the reduction in risk of dying from a cardiac event after quitting smoking is about 36 percent. So you could say that taking a statin offers an amount of protection from heart disease that is similar to quitting smoking.
Who should take statins?
There are many people who may benefit from statins. But not everyone needs to be on a statin – and of course, for each person, the decision must be a balance between the potential benefits and the risks of side effects.
The U.S. Preventive Services Task Force, a group that looks carefully at all the available evidence and makes recommendations on the preventive course that makes the most sense, recommends statins for certain people between the age of 40 and 75. If you fall in this age group and have some additional risk factors for heart disease (family history, diabetes, high blood pressure or smoking history), the USPSTF recommends taking statins to reduce your risk of heart disease. Importantly, the same guidelines also suggest that not everyone in this age group needs to be on statins. People at lower risk of heart disease, for example, may not benefit from the protective effect of statins, as their baseline risk of heart disease is so low.
In my practice, I try to have a conversation about statins with all of my patients in this age group. The only way to figure out whether taking statins is worthwhile for you is to talk about it, understand the risks and benefits in your case, and come to a decision together about whether to take statins.
Are there side effects associated with statins?
Statins have been extensively studied and prescribed. And all the data collected on patients on statins tells us they’re very safe. As with all medicines, there are some people who will experience mild side effects (with statins, the most common is muscle cramping), and others who will have more serious side effects, including liver toxicity and muscle damage. Of course, let your doctor know of any symptoms you may be having, and your doctor may order additional tests to see if these symptoms are related to your statin medication.
But all of the studies done on statins tell us that for most people, statins are safe. That same USPSTF analysis that examined the benefits of statins also looked at the risk of side effects. It found no significant difference in the rate of muscle pain, liver damage, or other serious side effects between people who were on statins and those who got a placebo.
Of course, if you experience a side effect, all the data in the world becomes irrelevant, so it’s important that the conversation with your doctor continues even after starting the medication. It’s also important that the conversation about side effects is couched in the context of the statin’s benefit to your heart health. That preventive pill may be a little easier to swallow with the knowledge that the statin may be reducing your risk of death from heart disease by 30 percent or more.
What about statins and the risk of diabetes?
The short answer to this question is that we don’t know definitively whether statins increase the risk for diabetes. Of all the major studies that analyzed statin use, only two studies suggested that more patients developed diabetes after starting statins. However, in both those studies, even among the patients who developed diabetes, there was about a 30 percent lower risk of having a cardiac event in the group that took the statin. And in the other 17 studies, there was no difference in diabetes risk. So the answer is still not clear. What is clear is that regardless of the potential diabetes risk, statins seem to help protect the heart.
So what’s the bottom line on statins?
The bottom line is that for most people, statins are an important part of reducing the risk of heart attacks and other cardiac events. Though they’re safe for most people, the balance of risks and benefits for each person depends on that individual’s risk of getting heart disease and the risks of side effects. The only way to figure out if a statin is right for you is to have a conversation with your primary care doctor about where the balance falls for you.