Should you be on statins?
, medical review by Dr. Bret Scher, MD
in Cholesterol, Heart disease 
Dr. Anders Tengblad
Should you be on a cholesterol-lowering medication, a so called statin? This is much debated and this will likely be a controversial post.
Some claim that nobody should take such drugs, that they cause lots of side effects and no benefits, as heart disease “has nothing to do with cholesterol.”
Others claim that most people (even healthy people) should take statins daily to prevent heart disease, as they are “effective and almost free of side effects.” Many doctors prescribe statins to all their patients with a cholesterol level above a pre-set number. For example a total cholesterol above 200 mg/dl (5 mmol/l).
Pros and Cons
The truth is of course somewhere between these extreme alternatives. Statins have been showed to reduce the risk of heart disease, especially in people who already suffer from heart disease. However, they also carry a risk of side effects, such as an increased risk of diabetes, muscle aches, weakness and increased fatigue.
So who could benefit from this medication? Should you be on it? New guidelines – a step in the right direction – have been issued from the Swedish Medical Products Agency.
Here’s a sensible guest post on the subject by Dr. Anders Tengblad:
Guest Post
If you’ve had a routine check-up, you may have had a comment about your cholesterol level, high or low, good or bad. If the level was high you’ve probably been advised to change your diet or take medication in the form of a statin. Unfortunately in my opinion many have been told to take statins needlessly. At the same time, some who should have had it will not have been given preventative medication, because their risk has been misjudged.
Under the new guidelines, statins should be used only when the overall risk of a cardiovascular event within 10 years is higher than 5%, no matter what your cholesterol level is (except, however, for LDL levels above 190 mg/dl (5mmol/l) in which case the person may have a genetic cause for the elevated cholesterol levels).
Treating according to the total risk rather than an elevated level is a new way of looking at treatment. In addition, medications that only impact the cholesterol number, but haven’t been shown to be beneficial for cardiovascular disease are essentially dismissed. This applies to multiple drugs. But the fact is that this also applies to low-fat foods, for example margarines, which in some cases may lead to a slightly lower cholesterol number, but other than that haven’t produced any benefit at all.
Although many now believe that atherosclerosis develops due to inflammation and not because of too much fat in the blood, it’s nevertheless a fact that statins may reduce the risk of myocardial infarction in patients at high risk for heart attack and that’s where they can do some good. Statin drugs have side effects, such as muscle aches, but can also produce a slightly elevated blood sugar. If you administer the drug to a patient with a low risk for heart disease, the net effect may be negative, but if the patient has a high risk, the benefit may outweighs the risk.
The risk of future cardiovascular disease has been estimated based on previous population studies and has been compiled into a risk calculator called Score. An internet-based version is available at: European SCORE guidelines.
If you enter numbers for a non-smoking 55-year old man with normal blood pressure and a cholesterol level of 270 mg/dl (7 mmol/l) into the risk calculator, the risk is 3% and statins are therefore not indicated. Similarly, the risk of a non-smoking woman at 65 with a normal blood pressure and a cholesterol of 270 (7) is only 3%, while the risk of a man at the age of 65 is higher and statins may be appropriate.
There’s also a risk calculator for those who have diabetes. There are more parameters to enter here, for example HDL, but the feeling is that many over 45 years of age with diabetes have an indication for a statin.
Some think that these risk calculations are based on factors that are too restrictive. Heredity, obesity, psychosocial stress, eating habits, etc. are not included, but these factors may both increase and decrease the risk for an individual. However, overall I think that focus on the overall risk rather than individual target numbers is a major step towards a better use of drugs.
All doctors are of course not updated on the guidelines yet. If at a check-up you are recommended to start taking a statin I think you should ask if the recommendation is based on a target number or a risk level.
Anders Tengblad
MD, PhD
Comment to the guest blog
I think this is a big step in the right direction. All doctors who prescribe statins – as well as their patients – should take away two things from the new guidelines:
- Under most circumstances, statins should not be taken just based on a certain cholesterol number.
- Instead, a high total risk of heart disease may make it worth medicating with a statin.
In practice this means – slightly simplified – that for people who already suffer from heart disease it’s often a good idea to take statins, and that it’s rarely worth risking the side effects from statins for people with a low risk of heart disease.
The problem with an LCHF diet
As Dr. Tengblad writes, the commonly used risk calculation is simplified. It only includes age, blood pressure, smoking and total cholesterol.
Simplifying to using only total cholesterol is a major problem for people who eat low-carb. The reason is that LCHF consistently – in repeated studies as well as in clinical practice – significantly raises the good cholesterol, HDL. A high number means a statistically much lower risk for heart disease. At the same time more HDL cholesterol means a higher total cholesterol and therefore very incorrectly that the simplified risk calculator will indicate a higher risk due to more HDL cholesterol despite the fact that the risk in reality is lower!
The error is not negligible. In practice if you have as an LCHF eater a high HDL number, for example above 58 mg/dl, or even above 77 (1.5–2 mmol/l), then you likely have a lot lower risk of heart disease than what the risk calculator will show. If you’re on the border to be recommended a statin then it’s probably worth evaluating more deeply. Other calculators, such as one from the American College of Cardiology, are somewhat better as they factor in HDL and a diagnosis of diabetes.
Conclusion
The simplified model is still true in most cases:
- People with heart disease often benefit from statins
- People without heart disease are less likely to benefit from statins
Those who are prescribed statins without any known heart disease should ask their doctor whether this is based on older population-based cholesterol reference numbers or the newer risk calculations. And if it is the latter you should, as an LCHF eater, ask about having your risk adjusted to your HDL number before making a final decision. Otherwise the chance of benefit may be small compared to the risk of side effects.
Lifestyle
Finally, of course we mustn’t forget that pills are only one way to impact your risk of heart disease. You can also significantly impact it with lifestyle changes.
Avoid smoking (of course) and try to maintain a good weight, a good blood pressure and blood sugar and a good cholesterol profile. A low-carbohydrate diet may help with all (except the smoking).
In the end, you may improve your health so much that statins would be completely unnecessary.
ADDENDUM- Since this post was written, the ACC/AHA has published newer guidelines that further help risk stratify patients. For patients at an intermediate risk of heart disease (defined as 7.5-20% 10-year risk of a cardiac event), the guidelines recommend further evaluation with a coronary calcium score prior to deciding on statin therapy. We see this as a definite step in the right direction as it can further help define those who are more or less likely to benefit from statin therapy. Of course we still wish there was more of an emphasis on lifestyle and reducing metabolic disease, but we hope those guidelines are coming soon!
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