You Have Heart Disease Risks. Should You Be Taking a Statin?

“Statins stabilize plaque in the arteries so it is less likely to rupture, they reduce inflammation in blood vessels, and they improve overall blood flow and vessel function,” says Sadeer Al-Kindi, MD, a preventive cardiologist and an assistant professor of cardiology at Houston Methodist in Texas. “Because of these effects, statins can help prevent heart attacks and strokes, even in some people whose cholesterol levels are not very high.”

Statins are medically indicated for adults with high cholesterol, established cardiovascular disease, diabetes or other chronic diseases, or a high calculated risk of future heart events.

"Statins are most useful in those patients at the highest risk of having a cardiovascular event, either initial or repeat events," says Michael Miller, MD, a Philadelphia-based cardiologist at Penn Medicine who specializes in preventive cardiology and a coauthor of The American Medical Association Guide to Preventing and Treating Heart Disease.

• Primary Prevention Even if you have no known heart disease and normal cholesterol levels, you may still be a candidate if a risk assessment tool estimates a high probability you’ll have a heart attack or stroke in the future.
• High Cholesterol Statins are the primary treatment for those with an LDL of 190 milligrams per deciliter (mg/dL) or higher or a triglycerides level of 150 mg/dL or higher.
• Chronic Disease People ages 40 to 75 with diabetes, chronic kidney disease (stage 3 and higher), or human immunodeficiency virus (HIV) are typically prescribed moderate-intensity statins.
• Established Cardiovascular Disease A high-intensity (higher dose) statin is recommended for those who already have atherosclerotic cardiovascular disease (ASCVD).
• Subclinical Atherosclerosis People with plaque buildup but no chest pain or shortness of breath, which is known as subclinical atherosclerosis, are also prescribed statins, but the intensity and dosage varies depending on the severity of calcium buildup in the arteries.

While LDL cholesterol is the primary target of statin therapy, these medications have other benefits, too. Dr. Al-Kindi says that LDL doesn’t tell the whole story, and that doctors are increasingly using other assessments to gauge who might benefit from statin therapy.

“Today is a great day to be a patient because we have newer tests available, such as coronary artery calcium scoring, apolipoprotein B, and lipoprotein(a), each serving distinct roles,” says Safwan Gaznabi, MD, a cardiologist at Loma Linda University Health in California.

• Coronary Artery Calcium (CAC) CAC is a heart scan that detects early plaque buildup in the arteries, which can show if heart disease has already developed, Al-Kindi says.

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   A high CAC result puts a patient in the same risk category as someone with established heart disease, Miller says, and can prompt intensified statin therapy.
• Apolipoprotein B (ApoB) ApoB is a particularly harmful protein found on the surface of several cholesterol-carrying particles.

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   An ApoB test can offer a more detailed picture of heart health risks, and a high measurement may call for starting or intensifying statin use.
• Lipoprotein(a) Lipoprotein(a), or Lp(a), is “much more artery-clogging than LDL,” says Dr. Miller, but your levels are genetically determined and remain stable over time. While statins do not lower Lp(a), they can help mitigate the risk caused by naturally high Lp(a) levels.

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• Sex
• Age
• Systolic blood pressure (the top number in a blood pressure reading)
• Total and high-density lipoprotein (HDL) cholesterol
• Estimated glomerular filtration rate (a blood test that measures kidney function)
• Body mass index (BMI)
• Smoking status
• History of diabetes, statins, and medications for high blood pressure

The calculator also offers the option to input urine albumin-to-creatine ratio (uACR), which is a urine test that detects early kidney damage; hemoglobin A1C, a blood test to diagnose and monitor diabetes; and even zip code, to account for the increased health risks associated with living in a community with limited resources.

"A higher ASCVD risk score and additional factors such as family history and chronic inflammatory illness can help determine if statin therapy would be an appropriate recommendation," Dr. Gaznabi says.

"Statins are safe,” Miller says. "Does that mean that everybody that takes a statin is going to be free of side effects? Of course not."

"I encourage all patients to address their concerns with their healthcare providers so we can find the right recipe for them," Gaznabi says.

• Statins are medications that lower LDL (“bad”) cholesterol, reduce inflammation, and help prevent heart attacks and strokes.
• Many eligible patients avoid using statins, which could be leading to preventable cardiovascular deaths and hospitalizations.
• Current guidelines recommend statins to adults with a known high risk of future heart events, high cholesterol, established cardiovascular disease, and diabetes or other chronic diseases.
• While concerns about side effects are common, research shows most are rare or overstated. Most experts believe that for the majority of people, especially those at higher risk for heart disease, the benefits of statins outweigh the potential downsides.