High Cholesterol: Should I Take Statins?

Cholesterol is a type of fat. Your body needs it for many things, such as making new cells. But if you have too much, it starts to build up in your arteries. The higher your cholesterol, the greater your risk for heart disease. Too much cholesterol in your blood can lead to a heart attack or a stroke.

There are two kinds of cholesterol:

• Low-density lipoproteins (LDL) are the "bad" cholesterol. LDL can clog your arteries.
• High-density lipoproteins (HDL) are the "good" cholesterol. HDL helps clear fat from your blood.

Triglycerides are another type of fat in the blood. If you have high triglycerides and high LDL, your chances of having a heart attack are higher.

A simple blood test tells you how much cholesterol you have. The test results are given in numbers. Your cholesterol numbers help your doctor know your risk of heart attack. To find out this risk, your doctor will also consider your age, your family history, your blood pressure, and if you smoke.

• LDL should be low. Your LDL goal depends on your risk of heart attack and stroke. If you are at very high risk, your goal may be less than 70. If you are at high risk, your goal is less than 100. If you are at moderate risk, your goal is less than 130. If you are at low risk, your goal is less than 160.
• HDL should be high. A good HDL goal is 40 or higher. An HDL level of 60 or higher is linked to a lower risk of heart disease. A high HDL number can help offset a high LDL number.
• Triglycerides should be less than 150. A level above 150 may increase your risk for heart problems.

High cholesterol is just one of several risk factors that make heart attacks or strokes more likely. If you have high cholesterol and another risk factor, heart attacks and strokes are even more likely. Some risk factors are things you may be able to control. Others are things you can't control.

Your doctor can help you know your risk of a heart attack or stroke.

Risk factors you may be able to control include:

• Diabetes.
• High cholesterol.
• High blood pressure.
• Smoking cigarettes.
• Being overweight.
• Not exercising.

Risk factors that you can't control include:

• Your age. Men age 45 or older and women age 55 or older have a higher risk.
• Having one or more close relatives who have or had early heart disease.

The two main treatments for high cholesterol are medicines called statins and the Therapeutic Lifestyle Changes (TLC) program, which includes being more active and changing your diet. The main goal of treatment is to lower your "bad" LDL cholesterol and reduce your risk of a heart attack or a stroke.

The way high cholesterol is treated will depend on your risk for a heart attack and your personal preference about taking medicines. For example:

• For people who are at moderate to high risk of a heart attack, research shows that statins lower the risk of heart attack and stroke. For these people, the United States National Cholesterol Education Panel (NCEP) recommends that they start taking statins right away. ^{1, 2}
• For people who are at low risk of a heart attack, experts are not sure how well statins lower this risk. ³ For these people, the NCEP recommends lifestyle changes as the first option to lower cholesterol. ¹

If you try lifestyle changes first, you and your doctor may want to set a deadline. For example, you might decide that you will try changing your diet and activity level for 3 to 6 months. If your cholesterol doesn't come down enough in that time, you may decide to start taking statins.

Why are lifestyle changes so important?

Some people can lower their cholesterol just by making lifestyle changes such as eating less saturated fat, losing weight, exercising, and quitting smoking. Others will need to take pills as well. But some lifestyle changes are important for everyone with high cholesterol. Even with statins, you will need healthy habits for the rest of your life to lower your risk of a heart attack.

What are the benefits of statins?

Statins and statin combinations are medicines that reduce the body's natural production of cholesterol. They make "bad" LDL cholesterol levels in the blood go down and help lower your triglycerides. Statins can also raise "good" HDL cholesterol. Statins may be used alone, or they may be combined with other medicines.

Statins and statin combinations can:

• Lower the risk of heart attack. ⁴
• Lower stroke risk. ⁴
• Reduce LDL. ¹
• Increase HDL. ¹
• Reduce triglycerides. ¹

What are the risks and side effects of statins?

Statins don't cause side effects in most people.

When side effects happen, they tend to include minor problems such as:

• Muscle aches.
• Tiredness.
• Upset stomach.

These may be bothersome but are not serious. Serious side effects are rare. These include liver and muscle problems, diabetes, and temporary memory problems. ⁵

Benefits if you have heart disease

*Based on the best available evidence (evidence quality: moderate )

Evidence shows that statins help people with heart disease by reducing the risk of death and heart attack. The quality of this evidence is moderate .

Take a group of 100 people who have heart disease . Here is their risk of death from any cause within the next 3 to 5 years:

• Without statins, 11 to 12 out of 100 people with heart disease will die. This means that 88 to 89 out of 100 will not.
• With statins, 8 to 9 out of 100 will die. This means that 91 to 92 will not.

Here is their risk of death from heart or blood vessel disease within the next 3 to 5 years:

• Without statins, 8 to 9 out of 100 people with heart disease will die from a heart or blood vessel problem. This means that 91 to 92 out of 100 will not.
• With statins, 3 to 4 out of 100 will die from a heart or blood vessel problem. This means that 96 to 97 out of 100 will not.

And here is their risk of a nonfatal heart attack (a heart attack that doesn't cause death) within the next 3 to 5 years:

• Without statins, about 8 to 9 out of 100 people will have a nonfatal heart attack. This means that about 91 to 92 out of 100 will not have one.
• With statins, 5 to 6 out of 100 people will have a nonfatal heart attack. This means that 94 to 95 out of 100 will not.

Benefits if you don't have heart disease

*Based on the best available evidence (evidence quality: borderline )

Evidence shows that statins may be helpful for people who don't have heart disease. The quality of this evidence is borderline .

Take a group of 100 people who don't have heart disease . Here is their risk of death from any cause within the next 3 to 5 years:

• Without statins, 4 to 5 out of 100 may die. This means that 95 to 96 out of 100 may not.
• With statins, 3 to 4 out of 100 may die. This means that 96 to 97 out of 100 may not.

And here is their risk of a nonfatal heart attack within the next 3 to 5 years:

• Without statins, about 2 to 3 out of 100 people may have a nonfatal heart attack. This means that about 97 to 98 out of 100 may not have one.
• With statins, 1 to 2 out of 100 people may have a nonfatal heart attack. This means that about 98 to 99 out of 100 may not.

Risks

Most evidence shows that statins are safe.

Some studies suggest that statins may increase your risk of diabetes, liver problems, and a rare muscle problem called rhabdomyolysis. But this evidence is not clear. It is inconclusive .

Understanding the evidence

Some evidence is better than other evidence. Evidence comes from studies that look at how well treatments and tests work and how safe they are. For many reasons, some studies are more reliable than others. The better the evidence is—the higher its quality—the more we can trust it.

The information shown here is based on the best available evidence. ^{3, 6, 7, 8, 9, 10, 11, 12} The evidence is rated using four quality levels: high, moderate, borderline, and inconclusive .

Another thing to understand is that the evidence can't predict what's going to happen in your case. When evidence tells us that 2 out of 100 people who have a certain test or treatment may have a certain result and that 98 out of 100 may not, there's no way to know if you will be one of the 2 or one of the 98.

Your doctor may recommend that you take statins or statin combinations if the benefits of statins outweigh the risks. Benefits might outweigh risks if:

• You have high "bad" LDL cholesterol and low "good" HDL cholesterol.
• You have diabetes, high blood pressure, or heart disease.
• You are at high risk of having a heart attack, or you already have heart problems.
• You have tried being more active and changing your diet, but these changes didn't lower your cholesterol enough.