Harvard Heart Letter

The new strategy for statins: Should you be taking one?

Guidelines for taking cholesterol-lowering drugs now target overall risk rather than cholesterol values.



Photos: Thinkstock

Discuss all of your risks for heart disease with your doctor to determine if you should take a statin.

For anyone who's had a heart attack or a stroke, or has chest pain with exercise or stress (angina), taking a statin makes a lot of sense. These cholesterol-lowing drugs slash deaths from cardiovascular disease by 20%. Doctors also recommend statins for most people with diabetes, because they face two to four times the risk of heart disease than people without diabetes.

But what about everyone else? For years, doctors prescribed statins based largely on cholesterol test results, aiming to cut total cholesterol to under 200 milligrams per deciliter of blood (mg/dL), and LDL ("bad" cholesterol) to under 100 mg/dL. But in November, new guidelines on statin use issued by the American Heart Association (AHA) and the American College of Cardiology proposed a major change to that strategy.

"The new guidelines shift away from a target-driven approach to a risk-driven approach," says Dr. Reena Pande, a cardiologist at Harvard-affiliated Brigham and Women's Hospital and an instructor at Harvard Medical School. Instead of striving to reach a specific cholesterol value, doctors should consider a person's entire cardiovascular risk profile, she explains.

Statin guidelines: A new prescription

The new guidelines recommend a daily statin for individuals who fall into the
following four risk categories:

  • anyone who has cardiovascular disease, including angina (chest pain with exercise or stress), a previous heart attack or stroke, or other related conditions

  • anyone with a very high level of harmful LDL cholesterol (generally a level at or above 190 mg/dL)

  • anyone with diabetes between ages 40 and 75

  • anyone with a greater than 7.5% chance of having a heart attack or stroke or
    developing other forms of cardiovascular disease in the next 10 years.

Estimating your 10-year risk

The guidelines describe four groups of people (see "Statin guidelines: A new prescription," at left). The biggest change is for those who don't have heart disease but are at risk for it. For them, doctors should use the risk calculator on the AHA's website to help determine if they should prescribe a statin. The calculator considers age, sex, race, total cholesterol, "good" HDL cholesterol, blood pressure, diabetes, and smoking history. The guidelines also help doctors choose the right statin at the right dose. For example, someone with a history of heart disease may need a high-intensity statin such as atorvastatin (Lipitor), while someone with a lower risk could take a low-intensity statin, such as pravastatin (Pravachol).

One thing the guidelines don't take into account, however, is family history, Dr. Pande notes. If one of your parents was diagnosed with heart disease before age 50, that puts you at higher-than-average risk. That's why you should work closely with your doctor to make a personalized plan to keep your cardiovascular system healthy—not only with statins and other medications but through your everyday habits, too. Taking a statin is not a free pass to an unhealthy lifestyle. It's just one part of the "staying healthy" puzzle, says Dr. Pande. Diet is an important part of that puzzle; so is regular exercise, which boosts HDL.

Food choices to lower cholesterol

To help nudge down your cholesterol level, avoid foods that contain trans fats and foods high in saturated fat—hamburgers, ice cream, and other high-fat meats and dairy products. Both types of fat raise harmful LDL cholesterol levels.

What should you eat instead? These grains, veggies, and fruits are especially high in soluble fiber, which grabs on to cholesterol and its
precursors in your gut, sweeping it away before it enters your bloodstream.

  • Oats

  • Barley and other grains

  • Beans (black, white, kidney, garbanzos, lentils, and others)

  • Eggplant and okra

  • Apples, grapes, berries, and citrus fruits

Possible side effects of statins

A small percentage of statin users report side effects, the most common being minor muscle aches (which can have many other possible causes). Other less common side effects are liver or digestive problems and a small increase in blood sugar. If you develop side effects on a statin, check if any other drugs you take—prescription, over-the-counter, or herbal—interact with statins. Last year, a study in the Journal of Clinical Lipidology found that many people who quit taking statins because of possible side effects were also taking an average of three other drugs that interfered with statin metabolism. Often, the drugs boosted statin exposure throughout the body. Doctors don't always pick up these potential interactions, so double-check with your pharmacist or online at www.health.harvard.edu/drugcheck. Taking a lower dose, using drugs that don't interact with statins, or trying a different type of statin can help.

In the end, says Dr. Pande, "you need to balance the low risk of these side effects with the potential benefit of lower risk of heart disease, stroke, and death. Have an open conversation with your doctor to consider your personal benefits and risks."