Understanding statins: A comprehensive overview

In her latest online article Dr Gosia Wamil gives us her insights into statins. She talks about current guidelines on statins, how high someone’s cholesterol should be to take statins, how long statins take to work, if the effects wear off, long term risks, safety concerns and if there’s any evidence-based alternatives to statins.

What are the current guidelines on who should be prescribed statins? How high should someone’s cholesterol levels be to take statins?

Statins are primarily prescribed for individuals at an increased risk of cardiovascular disease based on various factors, not solely cholesterol levels. Factors considered include age, family history of heart disease, smoking status, blood pressure level, diabetes, and cholesterol levels. The decision to prescribe statins is often guided by overall cardiovascular risk assessment tools like the ASCVD (Atherosclerotic Cardiovascular Disease) risk calculator (in the UK QRISK3 but there are also newer calculators based on AI analysis of electronic healthcare records which offer more accurate assessment of cardiovascular risk and can improve prediction who really need to be treated). 
 

The National Institute for Health and Care Excellence (NICE) in the United Kingdom provides guidelines for using statins to prevent cardiovascular disease in people who have never had a significant event (Primary Prevention- preventing the first occurrence) of cardiovascular disease, for adults aged 40 to 75 years with a 10% or greater 10-year risk of developing CVD (based on QRISK3). For secondary prevention (preventing recurrence of heart attacks and strokes), NICE recommends offering high-intensity statin therapy to adults with a heart attack or stroke or who have established atherosclerotic CVD.
 

NICE does not specify a particular cholesterol threshold for initiating statin therapy but emphasises using the QRISK3 tool to assess overall cardiovascular risk.

How long do statins take to work? Do the effects wear off after many years on the drugs?

Statins typically reduce low-density lipoprotein (LDL) cholesterol levels within a few weeks of initiation. However, achieving the complete efficacy of statins may necessitate several months for stabilisation. Importantly, the enduring efficacy of statins in mitigating cholesterol levels and diminishing the propensity for cardiovascular events is evidenced, with no indication of waning effectiveness observed even after prolonged use over many years, provided that they are consistently and appropriately administered.

LDL should be monitored, and the statin dose may need to be adjusted occasionally to achieve a good effect. 

What do we know about some of the long-term risk/reward trade-offs when it comes to taking statins for many years or even decades? Are there any safety concerns about long-term use?

Long-term statin use is considered safe and associated with significant benefits in reducing cardiovascular events. Statins are most effective if started very early, before the onset of heart disease, and they should be taken life-long to offer full protection. Some concerns about long-term use include potential muscle-related side effects (myopathy) and, rarely, liver enzyme elevation. Regular monitoring and reporting of any unusual symptoms to a healthcare provider are essential. A recent large meta-analysis from Oxford University showed that muscle pain, the most frequently reported side effect of statin, is wrongly attributed to statins in 90% of patients taking them.  

The benefits of long-term statin use in preventing heart attacks, strokes, and mortality often outweigh potential risks, especially for individuals at high risk of CVD.

Are there any known evidence-based alternatives to statins, particularly for those concerned about the side effect profile?

Given the highly favorable safety profile of statins they remain to be a cornerstone of clinical guidelines worldwide. Concerns regarding potential side effects or challenges with tolerance may prompt the exploration of alternative strategies. Lifestyle adjustments encompassing dietary modifications, regular exercise, and smoking cessation represent viable options. Additionally, alternative cholesterol-lowering medications, such as ezetimibe (usually prescribed as additive therapy in patients who have high cholesterol on statins or PCSK9 inhibitors, or a strategic amalgamation of these approaches may be considered.

PCSK9 inhibitors have gained popularity for effectively reducing LDL-C by around 50-60% or more, especially for those with high LDL-C levels or at a high risk of cardiovascular disease or those who have established heart disease. They are often used in addition to statins or for those who can't tolerate statins. Advantages include potent LDL-C reduction and being well-tolerated, though they come as injections and can be costly. Whether they are better than statins depend on an individual's specific health circumstances and considerations such as cost and administration preferences. The choice of treatment should be made in consultation with a healthcare provider.

Dr Gosia Wamil is an esteemed cardiologist with over 20 years of experience. You can schedule an appointment with Dr Wamil on her Top Doctors profile.