So you just got back from your doctor where you were told that you are at high risk for a heart attack and need to start a statin medication to lower your cholesterol. You then tell your wife who refers you to her best friend Jane. Jane says her brother was put on a statin and had all kinds of problems. Jane then refers you to the internet site where people report problems with medications. You read about muscle aches and something unpronounceable called rhabdomyolysis. You think to yourself “holy sh**” I’m not going to take this stuff. Your doctor has already scheduled a return visit in 3 months and you think to yourself “I’ll wait until my next visit to see if my cholesterol is still high.” If I had a nickel for every time I heard this story I could be a rich man. (I took some poetic license of course.)
Another statin story: In my concierge practice it is common for a new patient to schedule a “meet and greet” visit to decide if he/she wants to become a patient. During one interview I was told by the prospective patient that his current doctor wanted to put him on a statin and he wanted to know what I thought of statins. A very reasonable question I thought. I replied that I thought it was the best pharmaceutical discovery of the latter 20th century. He then stood up and left my office. Clearly he did not like my answer.
So why all this negative feeling about statins. The Wall Street Journal published an article stating that there is much more negative than positive on the internet. Some people write books describing their own feelings about statins and may even have an MD after their name. However if one goes to bona fide medical websites like the AMA, the National Institutes of Health, the Mayo Clinic and even WEBMD the attitude is the polar opposite.
The first statin Mevacor (lovastatin) was released in October 1987. I remember that date well because I had patients lined up to get started on this breakthrough medication. Prior to that we had primarily cholestyramine and Metamucil to treat high cholesterol. Both of these treatments were not very effective. In the next 10 years there were several improvements on the first statin. Pravachol (Pravastatin), Lipitor (Atorvastatin) and Crestor (Rosuvastatin) were subsequently released. As you can see all the generic names end in “statin”. These were drugs designed in the lab by brilliant pharmaceutical scientists. Designer drugs like these take a lot of research and development to bring to market. Consequently they were quite expensive when first released. Now they are all generic and relatively inexpensive. It is very likely that the dramatic reduction in death from heart attack in the last 30 years is in large part due to the statins.
The Studies: So what about the studies favoring statins…From the Framingham Study in Massachusetts we learned that a high LDL cholesterol was associated with heart attack and death. In the 1980s we learned a definitive cause and effect of LDL cholesterol on heart disease through a national cooperative study called the Lipid Clinic Research Trials. In the 1990s two landmark statin studies were done. One was called WESCOPS for the West of Scotland Primary Prevention study using Pravachol in Scottish men with high LDL cholesterol but no heart disease. One half the men were given Pravachol and one half were given a placebo. After 6 months they could see a difference in outcomes (fewer heart attacks in the Pravachol group). The study had to be stopped early because of such a dramatic difference. Another study in people with known heart disease called the 4S study (Scandinavian Simvastatin Survival Study) was done in the 1990s. This study had to be stopped early because of such a dramatic improvement in survival in those taking Zocor (simvastatin). There have been many other studies involving Lipitor and Crestor which all show benefit; and indeed it had been proven that lower is better in terms of LDL cholesterol. Despite some initial concerns it appears that one cannot get the cholesterol too low. There have been more that 15 studies with statins all showing benefits in preventing heart attack and/or stroke. Because of this incontrovertible evidence that statins prevent heart attack, stroke and death it is no longer considered ethical to do a placebo controlled study with statins.
Non drug treatment: If your cardiac risk is relatively low it is always reasonable to try weight loss, a low meat diet and exercise first. If your risk is high you should be on a statin. If you have heart disease, diabetes, have had an ischemic stroke, or have decreased circulation to your feet you should be on a statin, without question.
Calculation of risk of heart disease: The American Heart Association and American College of Cardiology have both endorsed a calculator available online to anyone. This is of particular value to someone with no evidence of heart disease or stroke but who has high cholesterol. This takes into account blood pressure, cholesterol, diabetes, gender, age and smoking. Because of its emphasis on prevention, my concierge practice of internal medicine utilizes this calculation of risk on every one. In many patients we also recommend a CT Coronary Calcium Score and an ultrasound of the carotid arteries to further stratify risk.
Side effects of statins: These are relatively uncommon. Approximately 5% of people on statins will get muscle aches. This is rapidly reversible if the drug is stopped. In patients who are Vitamin D deficient, taking oral Vitamin D may resolve these aches. Changing to a different statin or lowering the dose frequently solves the problem of muscle aches. One out of 50,000 patients taking a statin will get rhabdomyolysis. This involves the breakdown of muscle and subsequent kidney failure. This is exceedingly rare and more apt to occur if combined with another drug like fenofibrate (used to treat high triglycerides). I have never seen a case of statin- induced rhabdomyolysis in my career.
So, in summary, the risks of statins are low and the benefits are very high in people at risk for heart disease. These drugs have been rigorously examined in multiple studies and have stood the test of time. On top of that, they are inexpensive.
Don’t listen to the problems of the brother of your wife’s best friend Jane. Listen to your doctor and only review bona fide medical web sites on the internet. You may be convinced as I am that the discovery of statins is the most remarkable pharmaceutical advance of the latter 20th century.
EXPERIENCE CONCIERGE MEDICINE AT ITS BEST WITH DAVID G. WILSON MD WHERE PREVENTION IS KEY. With concierge care at David G. Wilson MD, we can keep you in the loop with vaccines and other important happenings for your health. Care with us is personalized, so we keep you in mind with new medical developments. Contact us to set up an appointment (same or next day) at 513-232-6900.
David G. Wilson, M.D.