The importance of cholesterol levels is a hot topic in the media lately, due in large part to the widespread use of statins to lower cholesterol. On a daily basis, when we review medications with patients who are coming for elective cosmetic surgery, we find that a large number are taking statins. Many who are candidates for surgery are in their fifth or sixth decade, a time when attention is paid to the prevention of heart disease and stroke. When we ask patients the reason they take statins, about two-thirds say their doctor prescribed them due to their high cholesterol or LDL numbers. As with every drug taken by a large percentage of the population in this country, there are pros and cons. Unfortunately, the guidelines for prescribing statins have been set, reset, altered, and influenced by new studies. Since such a large percentage of the population is taking statins to help prevent cardiovascular disease and stroke, it is important to learn more about them.

A recent article in the Washington Post noted that boosting good cholesterol did not help prevent heart attacks. This statement was based on an eagerly awaited study that included statistics about the effect of niacin on heart attacks and stroke. The study was federally funded at a cost of $52.7 million but was halted after 18 months because it became evident that the drug niacin, which boosts HDL levels, failed to reduce the risks of heart disease and stroke. In fact, it was noted that niacin might actually increase the risk for one type of stroke. It was thought that increasing HDL levels would decrease the risks, but this did not occur in the study. Interestingly, one HDL-raising drug (fenofibrate) failed to cut heart attacks and strokes among diabetics. Another HDL-raising drug (torcetrapib) increased the risk of these diseases. In one study, subjects on the statin Zocor had niacin added to their prescription, but after 32 months of follow-up, it became clear that the combination was no less likely to reduce the risk of a heart attack or stroke.

A recent article from the Associated Press reviewed some of the studies done on healthy people who take statins to lower their cholesterol in hopes of preventing heart problems. This question has brought divided opinions among heart doctors and also confused patients. One study done in 2008 by the maker of the drug Crestor (a statin) stated that it cut the risk of certain heart problems in half in middle-age older men and women who had normal LDL and high C-reactive protein levels. The article suggested a new use for Crestor and a new blood test for C-reactive protein to measure these results. Critics of this study questioned why the authors didn’t report the rates of death from heart attack and stroke, which turned out to be unaffected by Crestor. A third paper, an analysis of 11 published studies including the 2008 study, found no evidence that statins help high-risk people without heart disease live longer. Of course, cholesterol-lowering drugs including statins create a lot of income for the drug industry. There were 238 million prescriptions for cholesterol-lowering drugs in 2009, with $17 billion in sales. If statins do indeed have a protective effect on certain categories of patients, they should certainly be used. However, if the studies are controversial in terms of their results and a clear pathway is not proven, it’s probably better to wait to take them.

It is also important to sort out patients who actually have heart disease and those who are taking statins for primary prevention. The recent Jupiter Trial studied this problem but was criticized for providing “inflated estimates of benefits, understat[ing] harms, and allow[ing] findings to be published and used to advantage in marketing.” The conclusion was that “the results of the trial do not support the use of statin treatment for primary prevention of cardiovascular disease and raises troubling questions concerning the role of commercial sponsors.”

There are also risks to taking statins. Each person must weigh the benefits and risks for themselves so they can make a decision with their doctor. While statins do lower cholesterol numbers, are they worth the side effects and is the mortality rate really affected? According to a Mayo Clinic article, muscle pain and damage is the most common statin side effect. It can go on to a life-threatening problem called rhabdomyolysis, which causes severe muscle pain, liver damage, kidney failure, and death. Digestive problems, rashes, and neurological side effects can also occur. Some risk factors of taking statins are being on multiple cholesterol-lowering medications, being female, over 65, having a thinner body frame, and having diabetes. In studies of memory and cognition, it was shown that people who were on a statin drug did worse on testing than those on a placebo. It has also been noted that depression and irritability are more common, and violent behavior, psychoses, and suicide have been reported in some of these patients. If you are taking statins to prevent heart attack and stroke, you may be better off taking aspirin, doing exercise, and losing some weight. Additionally, fish oil, ground flax seed, garlic extract, oat bran, and Benecol may help reduce total cholesterol and LDL.

An interesting study from the Cleveland Clinic showed that high dose statin therapy could result in benefits when compared to a moderate lipid-lowering strategy. However, the statistical conclusions of the study showed that statin reduces the LDL and increases the HDL levels, but it could not show that these changes caused reductions in clinical events such as stroke or heart attack or that it improved the clinical outcome. There are many studies done which report benefits that either cannot be substantiated or are refuted by other articles on the same subject.

In conclusion, you must decide what your goal is. Do you want to prevent heart attack or a thrombotic stroke? If so, then discuss taking aspirin or Plavix with your doctor. If you want to prevent bleeding stroke, then you have to keep your blood pressure at a normal level. In general, getting regular cardiovascular exercise, eating fruits and vegetables, eating fish two or three times a week, avoiding all trans and hydrogenated fats, and consuming olive oil, chocolate, and other good nutrients will help ensure that you are at a much less risk for cardiovascular disease, maybe without taking statins—unless it is proven to help your particular medical needs. 

Dr. Carraway is the director of the Plastic & Cosmetic Surgery Center of EVMS. Call 757-557-0300 for more information.