Should You Take a Statin?

If your annual checkup reveals that your cholesterol levels are high, your doctor may recommend you take a statin—such as atorvastatin (Lipitor), sim¬va¬statin (Zocor), rosuva¬statin (Crestor), prava¬statin (Pravachol), or lovastatin (Mevacor)—to help lower your “bad” LDL cholesterol. Statins also can slightly raise “good” HDL cholesterol and may help lower triglycerides—blood fats that can increase heart disease risk, according to Weill Cornell Medical College. According to the National Cholesterol Education Program (NCEP) of the National Institutes of Health, 11 million Americans take a statin; another 25 million might benefit from one.

Prevention is key
Heart disease is the number-one killer of women, with stroke not far behind. A recent study of more than 2,700 women (Neurology, Feb. 20, 2007) showed that healthy women with no history of heart disease or stroke but with elevated cholesterol are twice as likely to suffer a stroke than women with lower cholesterol levels.

Antonio M. Gotto, Jr., MD, PhD, dean of Weill Cornell Medical College, says statin drugs are a valuable tool in controlling the cholesterol risk factor. For example, the Cholesterol and Recurrent Events (CARE) study showed that women who were heart disease survivors and took Pravachol instead of placebo did better than men in dodging another heart attack.

“Women overall tend to be at lower risk (for heart disease and stroke), but the studies show statins benefit them,” Dr. Gotto says.

Simeon Margolis, MD, PhD, professor of medicine and biological chemistry at Johns Hopkins School of Medicine in Baltimore, agrees that statins can help women keep cholesterol under control. “Initially, women were not well-represented in the studies,” Dr. Margolis says. “But now there is plenty of evidence that keeping cholesterol levels low prevents heart attack and stroke in women the same as it does in men. Young, old, male, female—it works.”

When to start statin therapy
Roughly half of your cholesterol is manufactured in your liver and other organs, with the rest coming from food sources, such as eggs, dairy products, meat, and poultry. The human body needs a certain amount of cholesterol to produce vital hormones and to manufacture bile salts for the digestion of food. But when cholesterol levels are too high, it can adhere to the walls of arteries to form plaque that blocks the flow of blood.

For women who have not had a heart attack or stroke, the NCEP advocates statins for those with LDL cholesterol of 190 milligrams per deciliter (mg/dl) or higher, even if they are not overweight and don’t have a family history of heart disease or any other risk factor, such as smoking, high blood pressure or diabetes. With two or more other risk factors, an LDL reading of 160 mg/dl or higher might justify a statin, according to the NCEP, with the goal of getting it down to 130 mg/dl.

Dr. Gotto likes to see LDL levels below 100 mg/dl, especially with higher-risk individuals, such as heart attack or stroke survivors or women with diabetes. “I think the guidelines are too high,” he says. And Dr. Margolis acknowledges that some cardiologists like to get LDL levels below 70 in their patients.

In addition to lowering LDL levels, statins also have ancillary benefits: they can relax stiff blood vessels, reduce inflammation (which is thought to be a contributor to heart disease), and inhibit clotting that can lead to heart attack or stroke. A link between statins and the possible prevention of osteoporosis also is being studied, according to Dr. Margolis.

What about side effects?
The most common side effects of statins, such as muscle pain, tend to come with the higher doses, Dr. Margolis says. “They go away if you stop the drug.”

Rather than discontinuing the drug, however, some physicians prescribe a different statin or a different dose to see if that reduces the side effect. A lower dose accompanied by another LDL-lowering drug, ezetimibe (Zetia), may help reduce the risk of developing muscle pain, says Dr. Gotto.

In very rare cases, the inflamed muscles can release a protein that damages the kidneys and can even lead to death. Statins also can cause liver problems in some patients, so make sure your doctor tests your liver function at least once a year.

Some women, such as those in frail physical condition, the very elderly, and those of Asian descent, also may be at greater risk for muscle pain side effects.

Lifestyle changes
What about controlling cholesterol through diet and exercise? The NCEP recommends such steps as part of any treatment. Lifestyle changes can lower cholesterol by up to 15 percent, according to Dr. Margolis, but statins may reduce it by up to 50 percent with few side effects, depending on the statin and the dosage.

Nevertheless, it’s a good idea, even if you are taking a statin, to use oils low in saturated fats, such as olive oil; roast or steam foods instead of frying them; eliminate trans fats from your diet (they increase LDL and lower HDL); use egg whites instead of whole eggs; and load up on complex carbohydrates such as oatmeal, bran, vegetables, and fruits. Aerobic exercise, such as a good walk, on most days of the week is also important.

WHAT YOU SHOULD KNOW ABOUT STATINS
Statins must be taken regularly to maintain lower cholesterol levels and can be expensive, even with insurance.
Statins have been shown to reduce heart attack and stroke in both genders.
Statins can lower LDL cholesterol by up to 50 percent. Lifestyle changes, at best, can lower LDL by up to 15 percent.

Muscle pain is reported in as many as seven percent of those who take statins but may ease with reduced dosage or another type of statin.