Understanding Statin Therapy and Who Should Receive It
There have been many significant advances in coronary care in the last 30 years. One of the most prominent of these is the development of statins, a category of drugs that helps reduce what we often refer to as ‘bad’ cholesterol.
The first statin was approved by the FDA in 1987 and over the years it has been increasingly prescribed by doctors all around the world. It has been used both as a preventative measure and to support those who have suffered a cardiovascular episode such as a stroke or have been diagnosed with a long-term condition like angina.
Here we look at what statins are and who should receive this type of therapy, asking whether some doctors are currently overprescribing or even misprescribing the drug to their patients.
What are Statins?
LDL cholesterol is thought to be potentially harmful because it can lead to deposits on the walls of arteries, causing narrowing and potentially leading to heart disease.
Statins are a group of medicines that help lower these LDL levels and therefore reduce the risk of developing heart disease and help slow the worsening of an existing condition.
Research by the American Heart Foundation found that patients given statins reduced by 25% their risk of a serious cardiovascular event such as a heart attack or stroke.
Another 7-year trial suggested a 32% reduction in all causes of death after 2 years with this dropping to a 13% reduction after 6 years. This latter trial, however, was carried out on high-risk individuals and did not look at the benefits for low-risk patients.
In particular, it didn’t focus on the important trade-off between statin benefits and its potential side effects for these individuals.
One of the contentious things about modern statins is that they are often prescribed as a preventative measure, for example, when someone is diagnosed as having high cholesterol. Rather than looking at reducing LDL naturally through diet and exercise, physicians may sometimes be too quick to prescribe and use a medicalized approach such as this.
Who Should Receive Statin Therapy?
There is no doubt that statin therapy is a useful medical intervention. If someone has had a heart attack or is at high risk for coronary heart disease, then it can certainly reduce their risk and help them live a normal, healthy life.
The trouble is that statins come with some significant side effects. While clinical trials suggest that around 5% of patients suffer from these, anecdotal reports from doctors suggest this could be as high as 20%.
Many patients, for instance, experience physical symptoms such as muscle pain, loss of muscle bulk and atrophy as well as weakness and cramping.
Others experience impairment of their cognitive function, including poor sleep, irritability, loss of concentration and even depression. There is evidence that prolonged use of statins also presents greater risks for diabetics.
Cholesterol level is sometimes taken as the be-all and end-all when prescribing a statin but it certainly doesn’t play as big a role as many doctors believe. A more important diagnostic tool is the individual’s 10-year risk of having a serious heart event such as a stroke combined with their coronary calcium score.
A prescription for statins should only be used for those at high risk of a future coronary event or individuals who have already had one. In these cases, statins play an essential role in reducing the chance of someone either having another heart attack or even dying. Similarly, someone with a coronary calcium score above 100 could be considered a good candidate for low dose statins because of their risk level.
Doctors and other health care professionals can opt for a one size fits all approach which isn’t suitable for everyone. Cholesterol is not just a simple choice between high and low LDL. It’s a lot more complicated.
LDL cholesterol is split into small and large LDL, for instance. The former causes fat to build up on arterial walls but the latter is essential for things like cell metabolism and structure and the production of vitamin D.
It’s important to assess each individual on their own merits rather than treat a perceived symptom. Someone with a low coronary calcium score who has never had a heart episode but has high cholesterol does not need to be put onto statins. The side effects are too great, individuals have to be on this medication for a long time and the payoff and it does not reflect the risk they are facing.
It’s much better to take a more flexible approach and look at ways in which the individual can, for example, change their lifestyle and maintain their cholesterol and their heart health naturally.
The author of these articles is Dr Ross Walker, one of Australia’s most esteemed cardiologists and a member of the Miskawaan Medical Advisory board.