Are Statins Really Worth Taking for High Cholesterol?

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Research has shown that statins are highly effective in reducing the risk of fatal heart attack and stroke. But some people are reluctant to take these life-saving drugs. They worry about taking medicine every day for the rest of their life or have heard that statins have undesirable side effects. What does science have to say about these concerns and others surrounding statins? We talked to UH interventional cardiologist Ian Neeland, MD, Director of the Center of Cardiovascular Prevention at University Hospitals, to learn more.

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Transcript

Macie Jepson

High cholesterol. You know, I always figured I would eventually get it. And then I would officially say that I'm old.

Pete Kenworthy

Yeah. Well, I'm not that old. And I do have high cholesterol. I've had high cholesterol for years, actually. And we both know it's not really all about age, right? I mean, genetics play a big part in high cholesterol, too. Now, I want it to be lower, but I'm also not sure I want to be on medication the rest of my life. Hi, I’m Pete Kenworthy.

Macie Jepson

And I’m Macie Jepson. And this is Healthy@UH. You know, it's interesting. I found some things about this medication. Before we continue talking about it, we should mention, though, that we are on Zoom for this podcast. We're trying our best to stay safe and away from each other. So, bear with us if the quality is a little Zoom-ish. There's a lot of information out there that would make people want to shy away from statins. I've heard they affect memory, muscles, even your chances of getting diabetes. These are commonly prescribed medications, but the more I looked into it, I wondered if they really should be. Joining us today is Dr. Ian Neeland. He is the Director for the Center of Cardiovascular Prevention at University Hospitals. First, thanks for joining us, Dr. Neeland.

Dr. Ian Neeland

Thank you for having me.

Macie Jepson

Let's talk about what cholesterol is exactly. I mean, we all have it. What purpose does it serve in our bodies?

Dr. Ian Neeland

Well, cholesterol is a fat-like, waxy substance that helps your body make cell membranes, many hormones and vitamin D. So, it's a very important component of the body's metabolism. And the cholesterol in your blood comes from two sources: the foods you eat and your liver. Your liver actually makes all the cholesterol your body needs. So, any excess cholesterol you get in your diet is on top of what your needs really are. Now, cholesterol and other fats are carried in your bloodstream as round particles called lipoproteins. And the two most commonly known lipoproteins are low density lipoproteins or LDL and high density lipoproteins or HDL. Now, you may have heard of these terms. LDL or bad cholesterol to contribute to the formation of plaque buildup in the arteries. That's called atherosclerosis. And this is linked to higher risk for heart disease and stroke. On the other hand, HDL stands for high density lipoprotein, and that's considered a good cholesterol. Now, HDL levels should be around 50 milligrams per deciliter in an individual, but you can raise your HDL by several means, including exercising for at least 30 minutes five times a week, quitting smoking, avoiding saturated fats and losing weight.

Pete Kenworthy

So, the big concern, I presume, is the LDL, right?

Dr. Ian Neeland

That's correct.

Pete Kenworthy

Right. So, there are medications out there that can lower our LDL or bad cholesterol sometimes by 50 percent. Right? So, I guess the question is, why wouldn't we take these medications? I heard one of your presentations that an Internet search of statin myths turned up 30 million results online. So, before we break down some of those myths, I guess the first question is why is there so much negativity about them?

Dr. Ian Neeland

Well, you know, I think there's a lot of misinformation out there on the Internet. And people are really confused about what's true, what's a myth. And then they don't necessarily speak to their doctors about these questions all the time. So, I think that it's really important to get the facts straight. Now, I do think there is, you know, generally a low desire to take medications long-term in most people. And also, I've heard, you know, because the medicine doesn't make you feel any differently, why should I take it? Many people have that myth. And the other thing is that a lot of people think that once your cholesterol is better on a statin that you can stop taking the statin. Unfortunately, what happens is your cholesterol will go right back to where it was previously in many situations. And you know, you’re no better from where you first started.

Macie Jepson

And perhaps the biggest myth of all is that they don't even work in the first place when it comes to preventing heart attacks. So, obviously, Doctor, you disagree. But what is the science behind that disagreement?

Dr. Ian Neeland

Yeah. So, that’s definitely myth number one. We do know over decades of research that statins and other lipid lowering therapies are very effective in reducing the risk for major vascular events, such as death from cardiovascular causes, myocardial infarction, which is heart attack, stroke, or needing a coronary stent or bypass surgery. We have data now from over 20 statin trials of over 135,000 patients that show that statins compared with placebo or no medication result in a 23 percent reduction in heart attacks, 17 percent reduction in fatal or non-fatal stroke, 19 percent reduction in death from cardiovascular causes and a 12 percent reduction in all-cause mortality. So, they definitely work. They're definitely effective for heart disease and death. And those are data that have been around forever. And I think that myth should definitely be dispelled.

Pete Kenworthy

So, it sounds like someone with higher cholesterol, for example, my cholesterol is around 220, 230. That's considered high. It sounds like people should just take statins then, but my guess is there are people who should avoid statins, who shouldn’t take statins. Right? So, you know, there's a lot of other stuff out there, right? Like statins cause dementia, or maybe people with a family history of dementia should avoid taking statins. Are there people who shouldn't be, who have high cholesterol and then who shouldn't be taking statins?

Dr. Ian Neeland

You know, certainly if you're allergic to the statin or the components of the statin medication, that will be a situation which you would want to choose an alternative medication. You mentioned about memory or dementia. Well, you know, the truth is that memory issues tend to occur in the same age group in people that take statins. So, it's really difficult to know if it's the statin or it's other factors. The initial concerns about dementia came from self reports to the Food and Drug Administration, but it turned out that many reports where people who took the drug for really one day only. So, it's unlikely that drug had had any effect whatsoever. And we do know that we have more reliable data that come from other studies, including over 20,000 people taking statins. And the result of that is that there's really no effect of statins on thinking or memory issues. And so, in general, although there are some potential side effects long-term for statins, in most cases, if your doctor has identified you as having high cholesterol and needing a statin, the risks greatly outweigh, or sorry, the benefits greatly outweigh the risks.

Macie Jepson

It really amazes me how many people out there picking on statins based on what you're telling us right now. But the fact of the matter is they are. I mean, we touched on this already. But I want to ask you again, Doctor, why is that? Why is there so much negative information out there?

Dr. Ian Neeland

Well, I think, you know, a lot of people may have some questionable side effects that that come up when they start a statin, and they've heard, you know, negative reports or anecdotal information or stories from friends and family. And a lot of times these are about muscle aches. So, you know, generally muscle aches are not dangerous and really there is only some discomfort. There are rare instances of severe muscle breakdown, could be dangerous for organs such as the kidneys, but these cases are extremely infrequent. And I haven't even seen a case since medical school many years ago. Now, there's some fair evidence that repletion of vitamin D, thyroid regulation and perhaps the medicine Coenzyme Q-10 may help decrease the muscle side effects of statins. And it's certainly reasonable to try them, but we know that most of the supposed side effects of statins are actually not due to statins. So, in one recent study published in the New England Journal of Medicine just this past month showed that in patients who had discontinued statin therapy because of reported side effects, in truth, 90 percent of the symptom burden elicited by a statin challenge was also elicited by placebo. So, most of the people who reported a symptom on statin of a side effect had the same side effect on placebo. And half of the trial patients were able to successfully restart their statins. So, these data really show that although there are side effects, they're very infrequent as being truly related to the statin, and most people can get through them and be on some dose of a statin for long-term benefit,

Pete Kenworthy

Like many things in medicine, the benefits far outweigh the risk. And it sounds like that's true here as well. You mentioned a moment ago, you talked about potential long-term side effects of statins. What are those? Like what are the… You talk about a lot of the myths that are out there, but are there actual side effects that, whether they should be concerning or not, what are they?

Dr. Ian Neeland

You know, so, just like any medication, as I mentioned, you have to weigh the potential risk to the benefits. I had mentioned that the one side effect will be muscle aches. That's called myalgias. And we know that, in general, there are several benefits to statins, and the longer you use them and have lower cholesterol, the bigger the benefit is, and the lower the risk for developing heart disease. On the other hand, as you said, there are small potential risks. One of those risks, for example, is development of diabetes. But what we know is that for every 255 patients receiving a statin for four years, only one of those patients may be diagnosed with new diabetes. And usually that occurs in people who are already at risk for diabetes. Now, they may have pre-diabetes, for example, or they may be very overweight, and this may have occurred anyway over time, regardless of the statin medication. So, other than the, you know, possibility of muscle aches, the remote possibility of diabetes, there really aren't any significant side effects of statins that occur in most people. There are rare situations of a liver or muscle injury, but again, those cases are extremely rare. And certainly the benefits in people who are at high risk for getting heart attack and stroke who have high cholesterol, who may have family history of heart disease will definitely outweigh those risks in the long-term. You know, what we do know is that from genetic studies, the longer your LDL cholesterol is as low as it can be, the better the risk, the lower the risk for heart disease. So, for example, 10 years on a statin with low LDL cholesterol might decrease your risk by 20 percent; 30 years by 40 percent; 50 years by 60 percent. So, there are people out there and families with genetic changes that make them have very low LDL cholesterol, less than 20.

Those people almost never get heart disease. And so, we, you know, we know that if we could, you know, put statins in the water and everyone could tolerate them, then the risk of heart disease would go down significantly. So, the longer you're on the statin which, you know, translating into lower cholesterol over time, the lower, the risk’s going to be. So, if someone in their 30s wants to, you know, really make a dent in the risk, long-term, you know, especially if they have a family history or they, they might have, you know, borderline risk factors, those are the people who are going to get the biggest benefit over time because their trajectory for heart disease will change drastically and dramatically by lowering the LDL cholesterol.

 

Macie Jepson

Is quitting these prescription medications mid-treatment or perhaps without even consulting physician a big issue in the medical community?

Dr. Ian Neeland

I think that is a big issue. I mean, people quit medications a lot of times without addressing it with their physician. You know, the most important thing is to discuss your questions and concerns with your doctor. And even if you're thinking about experiencing side effects, you want to be sure to talk it over with your physician. There are things that your doctor can recommend such as checking and restoring blood levels of vitamin D and thyroid, tweaking the dose of your statin or switching to a different statin medication that might have other effects. And many of these things can address the side effects that you're worried about. But the important thing is that, to keep taking your statin if your doctor has determined that it's beneficial for you in the long run. I always say that prevention is the best medicine. And statins are certainly one of the most important tools we have in cardiology to prevent heart attacks and strokes.

Pete Kenworthy

What's the magic number? Right? I mean, I mean, we know that you can lower your cholesterol with changing what you eat or getting some exercise. Obviously, genetics play a role there. And sometimes you're just a little bit out of luck. But is there a magic age? Is there a magic number? Like, OK, I'm 49 years old right now. Right? And my cholesterol is 220, 230. No doctor's ever told me that I need a statin. Right? Every time I've been to my doctor, which isn't as often as I should go, but once every year plus, they've said, you know, change what you eat a little bit or get a little bit more exercise. But never has anyone said you should be taking a statin. And then I'm guessing I'm not old enough. Or my cholesterol is not too high. There has to be some factor.

Dr. Ian Neeland

Well, I think it starts first of all with suspicion and knowledge. You know, I'm a preventive cardiologist, and so I focus highly on risk and long-term risk. And so, in order to, you know, to have an indication to be on a statin, you have to understand that in the context of someone's risk. So, you know, people who have heart disease already, people who have diabetes, people whose LDL cholesterol is very high, it's called severe hyperlipidemia, so that would be an LDL cholesterol greater than equal to 190. And then people with premature history of coronary disease, such as familial hypercholesterolemia, those people should really be on a statin. And so, those people who don't, you know, if patients do not meet those criteria, then it's all about what your long-term risk of developing a heart attack or stroke would be. And then that helps us guide whether or not you should be on a statin. So, in general, you know, people who are younger, who don't have any risk factors for heart disease can usually get away with lifestyle changes, diet and exercise. But as you age or develop any risk factors like high blood pressure, diabetes, obesity, inflammatory diseases, such as lupus or rheumatoid arthritis, all those things can enhance your risk for getting heart disease and would be an indication to go on a statin. Now, you mentioned, you know, diet and exercise. So, you know, to a moderate degree, changing your eating habits and getting some exercise can lower your bad cholesterol, specifically decreasing saturated fat in your diet, decreasing dietary cholesterol and increasing soluble fiber and plant sterols in your diet can lower your LDL cholesterol. On the other hand, exercise and weight loss can improve your triglycerides and raise your HDL cholesterol, that good cholesterol. But, you know, in general, the effects are relatively modest, usually about a 10 to 20 percent change, whereas statins can decrease your LDL cholesterol by over 50 percent in many cases.

Pete Kenworthy

So, if you put me on a statin, I can just go on eating my cheeseburgers and fried chicken all the time.

Dr. Ian Neeland

No. I wouldn't really put it that way. You know, diet has a lot of components in it. And even though the statin will help lower your cholesterol, a poor diet that's high in saturated fat, high in sodium or salt, you know, and low in potassium and essential nutrients can have negative effects on your health way beyond the cholesterol. First of all, high sugars are stored in your body as fat. So, even though you're not eating a high-fat diet, you will definitely gain weight by eating sugary drinks, like, you know, non-diet sodas, sugar-sweetened beverages. Things that are high in fat and cholesterol and sodium will cause blood pressure to go up and cause your triglycerides to go up. And triglycerides, you know, I mentioned briefly, but are another, you know, lipid risk factor that many people overlook. And so, we know that even if you could get your LDL cholesterol down to low levels with a statin, there are many other, these lipoproteins out there in your blood that contribute to heart disease that are not necessarily lowered by the statin, and the diet plays a really important role in that. So, you're not off the hook eating the cheeseburgers and fried chicken just yet.

Macie Jepson

So, conventional wisdom has always told us that what we eat affects our health, and it does. But what I'm hearing from you is that genetics play a huge role as well. And when it comes to high cholesterol, could you actually break that down for us?

Dr. Ian Neeland

Sure. You know, genetics do play a role in your cholesterol set point. So, in other words, the amount of cholesterol that the liver makes and reabsorbs from your bloodstream is primarily determined by your genetics. However, statin and other lipid lowering medications can alter how your liver handles cholesterol and drive down bad cholesterol to very low levels. Now, there are some genetic diseases associated with very high levels of cholesterol, such as familial hyperlipidemia, or FH, that can cause premature development of heart disease, heart attacks, and death. And those diseases which are, you know, genetic diseases can run in families and are very dangerous.

Macie Jepson

So, Doctor, you have the last say here. What would you like to say to everyone out there listening who might be on the fence about statins? What is your argument?

Dr. Ian Neeland

So, I would say, you know, talk to your doctor, see a preventive cardiologist, if you're concerned. We can address all of your questions. We can, you know, help you understand the risks and the benefits of taking medicines like statins as well as other medications to prevent heart disease and stroke. And it's really important to have the correct information and to feel comfortable in understanding what it means to take a statin. It also is important to understand, you know, what the myths are out there and what are the truths. And the only way to really do that is to, you know, sit down with someone who has expertise in these areas and really find out the nitty gritty of what you need to know. And it's, as always, it's important to check your numbers. So, many people don't know they have high cholesterol until their doctor checks it which may or may not be until someone's, you know, in their 40s or 50s. So, it's very important to get your numbers checked and know what your numbers are and know what your goals are. And I think that's, that will go a long way to helping you identify areas that, you know, you need to improve in. And if you get a good preventive cardiologist to work with you, you are guaranteed to lower your risk for heart disease, as much as possible and live healthier, longer lives.

Macie Jepson

Thank you for joining us, Dr. Ian Neeland, Director for Cardiovascular Prevention at University Hospitals. And remember, you can find and subscribe to this podcast on Apple Podcast, Google Podcast, Stitcher and wherever you get your podcasts. Search University Hospitals or Healthy@UH, depending on where you listen.

Pete Kenworthy

For more health news, advice from medical experts and Healthy@UH podcasts, go to UHHospitals.org/blog.