Statin Information

Statin drugs, or “HMG-CoA reductase inhibitors,” are the most widely prescribed class of cholesterol-lowering drugs. The top sellers as of this writing are atorvastatin (Lipitor), simvastatin (Zocor), and pravastatin (Pravachol). Other statins include fluvastatin (Lescol), lovastatin (Mevacor), and rosuvastatin (Crestor). Cerivastatin (Baycol) has been removed from the market.

Strong Benefits

Statin drugs dramatically lower cholesterol; they lower bad "LDL" cholesterol more effectively than other class of cholesterol-lowering drugs. They also lower triglycerides; and raise protective (i.e. "healthy") HDL-cholesterol. In addition, they have been shown to have a number of other possible heart-protective effects. For example, some may lower blood pressure. These drugs have also been found to have a number of other, more technical sounding effects, that protect against heart disease, like reducing "smooth muscle proliferation." Atorvastatin is very strong, stronger than simvastatin, which is stronger than pravastatin on a per milligram basis. Thus, to get the same effect, one might take 40 mg of pravastatin, 20 mg of simvastatin, or 10 mg of atorvastatin.

These drugs have been shown to markedly reduce heart attacks, and to reduce strokes as well as benefiting “peripheral arterial disease” (a disease that consists of ‘clogging’ of the arteries to the legs). Many studies have confirmed reduction in heart attacks and strokes. They also lower rates of death from heart attacks and stroke. Stroke reduction is not typical with cholesterol-lowering drugs, and probably results from some of the other benefits of statins (such as blood pressure reduction) rather than from LDL-cholesterol reduction.

SHOULD YOU BE ON CHOLESTEROL-LOWERING DRUGS?

This is a decision you must make with your doctor. The following should be taken into account.

Middle aged men with significant risk for heart disease probably benefit more than they are harmed, in terms of survival (The West of Scotland Study). Risk factors include hypertension, smoking, diabetes, premature heart disease in a first degree relative and low HDL. Those who do not have high risk for heart disease experience a lower rate of heart deaths, but not even a trend toward lower overall death rate (The Texcaps/ACAPS study). (The total death rate was infinitesimally higher in the statin group.)

As of this writing, no study has shown statins or any other cholesterol drugs to lower overall mortality in women; and epidemiologically, cholesterol in women does not have the same relation to mortality as in men. Although higher cholesterol is linked to a higher rate of heart attacks per se, it is not linked to overall cardiovascular death or to overall death; indeed, lower cholesterol is linked to a slightly higher risk in some studies. Consistent with this, there is a decided reduction in heart attacks in women with statins, but the death rate overall -- or even cardiovascular death rate - has not been shown to be reduced. It is possible that there are subgroups of women for whom statins confer benefit exceeding risk, but this has never been demonstrated.

No studies have examined the impact of statins in randomized trials in those over age 75. Epidemiological studies show higher cholesterol to be protective, rather than harmful, in this age group, so it cannot be assumed that lowering cholesterol confers benefit exceeding risk. Low cholesterol may be a risk factor for heart arrhythmias, which are the leading cause of death if heart attacks occur; and in the elderly, a heart rhythm abnormality called atrial fibrillation, that may be increased with low cholesterol, is a particularly important risk factor for stroke in the older elderly. It is possible that there are subgroups of those over age 75 for whom statins confer benefit exceeding risk, but this has never been demonstrated. This would most likely be the case in persons at very high risk of death from heart disease, who are at comparatively low risk for other illness and injury.

Who should be on cholesterol-lowering drugs: the view of the National Cholesterol Education Panel (NCEP)

(A review by the British Columbia Office of Technology Assessment reviewed cholesterol guidelines from around the world on the basis of how complete their evaluation of the literature was; and to what degree the recommendations actually reflected the evidence; the NCEP guidelines were found, at the time of that review, to be among the least evidence-based. The guidelines have changed since that review, though there are similar flaws in the evidence base and the inferences drawn.)

	Begin treatment if:	Continue treatment till:
You have < 2 risk factors	LDL ≥ 190 (mg/dl)	LDL < 160 (mg/dl)
You have 2 or more risk factors	LDL ≥ 160	LDL < 130
You have known cardiovascular disease	LDL ≥ 130	LDL < 100

Statins Are Widely Used Drugs

Strong Benefits

SHOULD YOU BE ON CHOLESTEROL-LOWERING DRUGS?

This is a decision you must make with your doctor. The following should be taken into account.