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My Cholesterol Levels Are Up—Do I Need to Take a Statin?

My Cholesterol Levels Are Up—Do I Need to Take a Statin?

Here's what one cardiologist had to say.

Heart disease is the leading cause of death among adults in the United States, and high levels of unhealthy blood cholesterol can increase your risk of the condition. Both heart disease and high cholesterol can also raise your likelihood of having a stroke.

To reduce this threat—and your risk of related complications—doctors may prescribe cholesterol-lowering medications, such as statins, along with other lifestyle interventions.

A healthy diet and regular physical activity are beneficial, whether you have high cholesterol or not. Statins, however, are used only in specific instances. As with any medication, there are guidelines for prescribing statins, and not everyone fits the parameters.

To better understand who might be best served by taking statins, we spoke with cardiologist Rakesh Shah, MD, of Clear Lake Regional Medical Center in Webster, Texas. Here's what he had to say about guidelines, side effects and more.

What you should know about cholesterol
Cholesterol is a waxy substance found naturally in our cells. Although our bodies need it for many functions, such as hormone production and digestion, too much of it—or an abundance of the bad kind—can build up in the arteries and increase the risk of stroke and heart attack.

There are two main types of cholesterol. Low-density lipoprotein (LDL) is the bad kind of cholesterol that can build up in your arteries, while high-density lipoprotein (HDL) is the good kind that carries excess cholesterol to the liver, so it doesn’t get stuck to vessel walls. From there, it's removed from the body.

Your body makes all the cholesterol it needs for essential function, so you don't have to worry about getting the nutrient in your diet. Dietary cholesterol actually has little effect on your blood cholesterol. Keep in mind however, many high-cholesterol foods, such as red meat, full-fat cheese and certain vegetable oils, such as coconut oil and palm oil, are also high in saturated fat, which has a much more significant impact on your cholesterol levels.

To determine your cholesterol levels, your healthcare provider will have a blood sample taken and tested at a lab. Your doctor will consider these results, along with your history of high blood pressure and diabetes, to determine your risk of developing heart disease or stroke within the next 10 years. Your provider's analysis will determine whether medication to reduce your cholesterol is needed.

Recommendations for cholesterol screenings vary, but the American Heart Association (AHA) suggests most folks get their levels tested every 4 to 6 years beginning at age 20. It's best to speak with your doctor about the screening schedule that makes the most sense for you, based on your health profile.

Lifestyle modifications to try
If a routine screening reveals higher than normal levels of blood cholesterol, your doctor will likely prescribe a course of treatment.

In clinical practice, attempting to lower cholesterol with tweaks to your daily habits is always the first goal, according to Dr. Shah. "Lifestyle modifications are the number one treatment for any medical problem, including high cholesterol," he says.

Your doctor will likely advise that you adopt a healthy diet and a regular exercise regimen. If you smoke, they may also encourage smoking cessation. “Depending on your initial level of cholesterol, you may be able to lower your levels enough to avoid taking medication," Shah says.

Once you have discussed the lifestyle strategies that make the most sense for you, your doctor may advise:

  • Limiting saturated fat to 5 or 6 percent of your daily calorie intake
  • Adopting the DASH diet (designed to lower high blood pressure, but beneficial as well for overall heart health)
  • Increasing the amount of walking you do during the day—to work, at the office, during your lunch break, etc.
  • Getting the help you need to quit smoking

When your doctor may prescribe a statin
If these tactics fail to reduce cholesterol to a level your doctor deems acceptable, they may prescribe a statin.

Research suggests lowering cholesterol with statins can reduce the risk of stroke and heart attack by preventing additional plaque buildup and restoring function of the endothelium. The endothelium is the thin lining of the heart and blood vessels that helps control blood clotting and vascular relaxation and contraction.

Other cholesterol-lowering medications can be prescribed, but statins are often the drug of choice. "Statins have conclusively been shown to prevent heart attack and stroke," Shah says.

Not everybody needs a statin, he notes. Between 30 and 40 percent of his heart patients have been prescribed statin medications for one reason or another.

Your doctor will decide if you need a statin based on your age, cholesterol level, medical history and other individual risk factors for heart disease. In 2018, the AHA, the American College of Cardiology and 10 other health organizations, published updated guidelines for prescribing statins, calling for a personalized approach to the treatment of high cholesterol. In the past, doctors prescribed statin medication based on blood test results and factors like blood pressure and history of smoking. Doctors are now advised to consider other factors, like their patients' family history of heart disease, ethnicity and history of conditions like kidney disease, psoriasis, premature menopause or preeclampsia.

If additional information is needed, your doctor may also order a heart CT scan, or an imaging test called a coronary artery calcium (CAC) test for people between the ages of 40 and 75. This allows your doctor to identify and measure calcium-containing plaque in your arteries.

The calcium in your heart is different from the calcium in your bones and isn’t directly related to how much calcium is in your diet. Calcium is included in plaque that builds up in your arteries. The results of your CAC test can help your doctor determine if you’re at risk for heart disease—even before you develop signs or symptoms.

The goal for patients with a history of heart attack, stroke or arterial disease in the legs is to reduce cholesterol by at least 50 percent using statin medication, according to Shah. "It doesn't matter what their initial cholesterol level is, we try to reduce them by half for the maximum benefit," he says.

Statins have some side effects
Statins are typically well-tolerated when taken to control high cholesterol, and adverse reactions are less common among people taking these drugs than with other cholesterol-lowering medications. But they're not entirely without side effects.

"Anywhere from 5 to 25 percent of patients will report side effects," Shah says. "The most common ones we encounter are muscle and joint discomfort."

Severity and types of pain vary and may include anything from a dull soreness to excruciating pain, along with weakness that can make climbing stairs, rising from a seated position and lifting arms a challenge. The onset of symptoms usually happens within a few weeks or months of beginning statin therapy, but can occur at any time during treatment.

Don't hesitate to speak with your provider about side effects that bother you or won't go away. Muscle pain is usually bearable, but can often be alleviated as needed by changing the dose or switching to a new type of statin.

Before switching medications, dose or frequency, Shah will first determine whether discomfort is the result of drug interactions or an underlying condition. Although it’s rare, muscle pain may also signal a severe form of damage known as rhabdomyolysis. In extreme cases, this condition can lead to liver damage and even death.

Severe side effects occur most often in otherwise sick patients, and those with conditions such as biliary obstructive disease, a blockage of the ducts that carry bile from the liver and gallbladder to the small intestine. Physicians typically monitor patients with conditions like hypothyroidism, liver disease and kidney disease, as having these conditions can increase your risk of side effects.  

Speak with your doctor about side effects like fatigue, weakness, loss of appetite or yellowing of the skin, which could signal liver problems. Allergic reactions can include swelling of the face, lips, tongue and throat and difficulty breathing or swallowing, which may require immediate medical attention.

Despite the potential downsides, Shah believes statins are generally worth taking for certain patients. “When we prescribe statin medication, the benefit outweighs the risk of having side effects,” he says. “And it's always good to follow your doctor's advice."

If statins are ineffective, or if the side effects of these drugs are intolerable, your doctor may recommend a newer cholesterol-lowering drug, such as a PCSK9 inhibitor, which helps the liver remove more LDL cholesterol from the blood and limits the amount of plaque that can build up in the artery walls. Another drug called, ezetimibe, is also available and typically added to statin therapy when more LDL reduction is needed. It works by preventing the absorption of cholesterol in the intestine. Bempedoic acid, which targets a specific liver enzyme and was approved by the U.S. Food and Drug Administration (FDA) in 2020, may also be combined with statins in certain cases. Your doctor will be your best resource to help determine what medications are right for you.

It’s important to ask questions, voice concerns and work together to create a cholesterol treatment plan that helps keep your health on track while being as conducive as possible to your lifestyle.

Medically reviewed in January 2019. Updated in February 2020.

Sources:

Centers for Disease Control and Prevention. “Heart Disease Facts,” “Know Your Risk for Heart Disease.”
Mayo Clinic. “Heart Disease,” “Eggs: Are they good or bad for my cholesterol?”
MedlinePlus. “Cholesterol,” “Top 5 lifestyle changes to improve your cholesterol,” “Statins: Are these cholesterol-lowering drugs right for you?” “Statin side effects: Weigh the benefits and risks.”
American Heart Association. “Control Your Cholesterol,” “How To Get Your Cholesterol Tested,” “Prevention and Treatment of High Cholesterol,” “Cholesterol Medications,” “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.”
SELFNutritionData. “Egg, whole, raw, fresh,” “Beef, variety meats and by-products, splle, cooked, braised,” “Cheese, cheddar.”
American College of Cardiology. “ASCVD Risk Estimator Plus.”
UptoDate.com. “PCSK9 inhibitors: Pharmacology, adverse effects, and use,” “Statin muscle-related adverse events.”
Michael Nedelman. “Should you take statins? Guidelines offer different answers.” CNN.com. January 1, 2018.
American Family Physician. “ACC/AHA Release Updated Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk.”
U.S. Food and Drug Administration. “Controlling Cholesterol with Statins.”
NIH Daily Med. “LIPITOR- atorvastatin calcium tablet, film coated."

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