Statins is the term we use to describe a group of drugs that block an enzyme that is integral to the process by which the liver makes cholesterol. They include the drugs rosuvastatin (Crestor®), atorvastatin (Lipitor®), simvastatin (Zocor®), pitavastatin (Livalo®), pravastatin (Pravachol®), lovastatin (Mevacor®) and fluvastatin (Lescol®).
In my 25 years as a cardiologist, I don’t think there is another class of drugs that has created so much controversy about its pros and cons—and that controversy has puzzled me. Most of the skepticism is found on the internet; within the physician community, there is not much debate about the benefits of these drugs. While all medications have potential side effects—and statins are no exception—they are not unusually dangerous. In fact, they are safer than many medications that people take without a second thought—like aspirin. Furthermore, they are the single-most effective medication in reducing the development or progression of coronary artery disease. Statins have been tested in people who have already had heart attacks, as well as in people who haven’t had one, but are at higher risk. In these groups of people, they lower the risk of dying, having a heart attack or needing emergency angioplasty or bypass surgery, or having a stroke by anywhere from 25-50%, depending on the study population.
The most common side effect of statins is muscle achiness and it is this that makes some patients shy away from starting a statin. However, 90-95% of patients have no muscle side effects at all. Less common is actual inflammation of the heart muscle, termed myositis. This occurs in fewer than 1% and resolves with discontinuation of the drug. Very rarely, severe muscle breakdown—termed rhabdomyolysis—can occur. This is seen in fewer than 1 in 1000 patients and is more likely in the elderly, in patients on the highest dose of a statin and in patients taking other drugs that can affect muscles, like fibrates (a class of medication that lowers triglycerides).
Increases in liver enzymes can be seen in 1-2% of patients, but this, too, is generally reversible, and the likelihood of actual liver dysfunction is extremely low. Reports that statins can cause diabetes relate to the fact that they can increase sugar levels slightly, enough to—on average—raise a person’s Hemoglobin A1C (Hgb A1C) by 0.1. Since a level of 6.5 defines diabetes, a person who goes up from 6.4 to 6.5 has “developed diabetes.” But this reflects that people who develop diabetes on a statin are generally those who were very close to having diabetes anyway.
Finally, there is controversy on the effects of statins on brain function. Initially there was fear that too low a cholesterol level would lead to problems because nerve cells (the main functional cell in the brain) need fat to form myelin, a sheath around the nerve fiber that enhances transmission of impulses. However, that theory is not supported by the fact that people who achieve super low levels of LDL cholesterol on the new PCSK9 inhibitor medications (Repatha® and Praluent®)—levels below 30—have not demonstrated any neurologic problems. Still, there are patients who seem to experience memory issues on statin medications. This is rare and, in my experience, the problem resolves when the patient stops the statin. At the same time, there is data that statins actually benefit cognitive function, some studies showing a lessening of dementia. And there is definitely a reduction in stroke risk, which translates into better protection of brain function.
So, while statins can cause side effects in some people, the upsides to patients at increased risk of coronary heart disease are generally greater than the downsides. And, in patients who have had a heart attack, the benefits outweigh the risk by a factor of 5 to 10. Therefore, don’t let the scary things you read on the internet keep you from taking these potentially life-saving medications. Discuss the pros and cons of statins with your own doctor.
Greg Koshkarian, MD, FACC