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What Is a Statin and Should I Take One?

Contributor: Paul Ridker, MD, MPH
8 minute read
A Black man wearing glasses, a blue undershirt and overshirt, is sitting on the couch and pouring out a few tablets from his right hand to his left palm

Statins are among the most prescribed drugs in the United States. Yet a recent study suggests that only 35% of people who could benefit from these cholesterol-lowering drugs are taking them. The study, published in 2023 in the Annals of Internal Medicine, also found that most adults with the highest risk for a first heart attack or stroke aren’t getting statins.

“Statins are a very effective treatment for reducing high cholesterol and risk for heart attack and stroke,” says Mass General Brigham cardiologist Paul Ridker, MD, MPH. Dr. Ridker cares for patients at Brigham and Women’s Hospital.

How do statins work?

Cholesterol is a necessary fat that the body needs to function. The body produces cholesterol in the liver. From there it travels in the bloodstream. You also get dietary cholesterol from eating certain foods, mainly animal products such as meat and dairy and some tropical oils like coconut oil.

“The most important component of cholesterol to know is low-density lipoprotein (LDL),” says Dr. Ridker. LDL is commonly called “bad” cholesterol because it can cause fatty deposits (plaque) to build up in the arteries.

Cholesterol also contains high-density lipoprotein (HDL) or “good” cholesterol, which removes excess LDL from the body. When there’s too much LDL and not enough HDL, plaque can block the flow of blood or cause blood clots, leading to heart attack and stroke.

If you’ve never had a heart attack or stroke, lowering your LDL cholesterol helps reduce your risk of having one. If you already have cardiovascular disease, it decreases your risk of having another event. Statins help prevent heart disease and stroke by slowing LDL production in the liver to treat high cholesterol (hyperlipidemia) and reduce plaque buildup.

“Controlling your cholesterol with a statin can cut your risk of heart attack and stroke by 30%,” says Dr. Ridker, referring to previous research in the New England Journal of Medicine. “It’s like putting your seatbelt on when you get in a car. We’re trying to lower your risk of a bad outcome that’s otherwise avoidable.”

For the vast majority of people, statins are overwhelmingly our first-line recommendation to lower cholesterol and lower risk of heart attack and stroke.

Paul Ridker, MD, MPH
Cardiologist
Mass General Brigham

When to start statins

The American Heart Association (AHA) suggests that anyone with a history of atherosclerotic disease (plaque buildup) should consider statin therapy with an aim of getting their LDL level below 70 milligrams per deciliter (mg/dL).

For people who don’t have a history of atherosclerotic disease but who are at high risk, the AHA strongly suggests statin therapy when LDL is greater than 190 mg/dL.

Dr. Ridker notes that statin therapy should also be considered for people with lower LDL levels if they have diabetes, high estimates of lifetime risk, or a strong family history of heart disease at a young age. “For these ‘primary prevention’ patients, the goal of statin therapy is to get LDL lower than 100 mg/dL,” he says.

Some factors that can put people without heart disease symptoms at higher risk are:

  • Chronic kidney disease

  • Coronary calcium levels as detected by a coronary artery calcium (CAC) scan, which can indicate coronary artery disease

  • Diabetes

  • High levels of lipoprotein(a) (greater than 50 mg/dL), a type of LDL

  • Inflammation, indicated by C-reactive protein (a protein made by the liver) greater than 2 mg/L

  • Peripheral arterial disease

  • Strong family history of heart disease at a young age

Because you can have high LDL cholesterol and not have symptoms, it’s important to have your cholesterol checked regularly. “For the vast majority of patients, the only way to detect this is by measuring cholesterol with a simple blood test, which is typically done as a routine part of your annual checkup,” says Dr. Ridker.

Lifestyle changes to reduce cholesterol

Exercise and eating a balanced diet can also help lower cholesterol.

If you’re healthy but your cholesterol is high, your doctor may suggest lifestyle changes to reduce your LDL before trying a statin:

  • Exercise more: Activity increases HDL cholesterol, which helps reduce LDL cholesterol.
  • Improve your diet: Avoid foods that are high in cholesterol, saturated fats, and trans fats. Add more soluble fiber, vegetables, and omega-3 fatty acids to help lower LDL and raise HDL. Focus on healthy oils, vegetables, legumes, whole grains, poultry, and fish.
  • Lose weight: Extra weight can raise LDL and lower HDL. Losing 5% to 10% of your weight can significantly reduce bad cholesterol.
  • Stop smoking: Nicotine damages the lining of blood vessels, increases bad cholesterol, and decreases good cholesterol. Quitting improves your blood vessels and HDL.

If you’re unable to reduce your LDL cholesterol enough with lifestyle changes alone, your doctor may suggest adding a statin. Higher-risk patients who have existing heart disease or genetically high LDL (familial hyperlipidemia) may need to start a statin right away in addition to implementing these lifestyle changes.

“Using a statin isn’t a replacement for healthy living. Diet, exercise, and smoking cessation all lower cardiovascular risks and they're all really important,” says Dr. Ridker.

Which cholesterol-lowering drug is right for me?

There are many approved statins on the market, including atorvastatin (Lipitor®), rosuvastatin calcium (Crestor®), simvastatin (Zocor®), and pitavastatin (Livalo®). If one medication isn’t effective, your doctor can adjust your dosage, switch you to a different statin, or try a combination of statins. Statins can also be combined with other cholesterol-lowering medications such as ezetimibe and bempedoic acid.

Side effects of statins

Since the first statin was approved by the U.S. Food and Drug Administration (FDA) in 1987, many studies have shown that these medications are effective and safe.

“The biggest change in practice over the last few decades is the knowledge that they're remarkably safe. Therefore, patients at relatively lower and lower thresholds of risk are eligible to take these drugs,” says Dr. Ridker.

Muscle pain and weakness are rare side effects of statins that generally go away over time. But Dr. Ridker says muscle pain while taking a statin can often coincide with a different cause. More than 90% of people who experience muscle pain while taking a statin aren’t actually affected by the statin, according to a 2022 study in The Lancet.

For some people, taking statins may slightly raise their risk of type 2 diabetes. A recent study in The Lancet Diabetes & Endocrinology found that statins slightly raise glucose (blood sugar), and may reveal underlying diabetes among those who already are pre-diabetic with borderline glucose levels.

“As with any intervention, you need to discuss the risks and benefits with your physician because he or she will know about other things in your history that might matter. But for the vast majority of people, statins are overwhelmingly our first-line recommendation to lower cholesterol and lower risk of heart attack and stroke,” says Dr. Ridker.

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Paul Ridker, MD, MPH

Contributor

Paul Ridker, MD, MPH
Cardiologist