The majority of heart attacks are caused by unhealthful lifestyles, not by genetic defects. However, in 2014, the American College of Cardiology/American Heart Association (ACC/AHA) published data showing the importance of statins as the major drugs to treat high blood cholesterol levels and reduce susceptibility for heart attacks (J Am Coll Cardiol, 2014;63(25 pt B):2889-2934).  Statins remain the major choice of preventative drug, but everyone should realize that many studies show that lifestyle changes are probably more effective than statins in preventing heart attacks.

The previous recommendation was that statins should be given to everyone with a bad LDL cholesterol over 100 and to anyone who has had a heart attack. The latest guidelines recommend statins to reduce heart attack risk, not just to lower cholesterol (JAMA, 2017;318(5):417-418). These guidelines are to prescribe statins to people who have had a heart attack, those at high risk for a heart attack and those who have a genetic susceptibility for heart attacks.

Predicting High Risk for a Heart Attack
If you have three or more of these factors, you are at increased risk for a heart attack. Your doctor can examine you and order all of these tests:
• Blood pressure >120/80 at bedtime (when blood pressure is lowest)
• LDL (bad) cholesterol>100
• HBA1C>5.7 (diabetes)
• CRP>1 (inflammation)
• Abdominal obesity
• Small hips
• Resting heart rate >70
• Lp(a)>125 (blood test for a genetic disorder)
• Triglycerides >150
• HDL (good) cholesterol<40
• Homocysteine>10 (genetic or vitamin deficiency)
• Small LDL particle size (an indicator of diabetes)
• Family history of heart attacks

Coronary Artery Calcium Score
Half of the people who are identified as being at high risk for heart attacks, but have never had a heart attack, may not be at high risk if their coronary artery calcium score is normal (J Am Coll Cardiol, 2015;66(15):1657-1668). This test uses a CT scan x-ray to measure the buildup of calcium in arteries leading to the heart which indicates the size of plaques on the walls of the arteries.

Try Lifestyle Changes First
If you have one or more of the risk factors listed above, see if you can correct them with lifestyle changes. I believe that everyone should:
• lose weight if overweight (I recommend intermittent fasting)
• exercise
• avoid smoking
• not take in alcohol regularly or excessively (more than two drinks in a day)
• eat a healthful diet with plenty of fruits, vegetables, nuts and other seeds
• avoid sugared drinks including fruit juices, sugar-added foods, red meat, processed meats and fried foods
• keep hydroxy vitamin D levels above 20 ng/ml

If You Need Drugs
If you have had a heart attack or if you are at high risk based on the factors listed above, your doctor will probably start you on high-dosage, high-intensity statins (such as Lipitor 80 mg/day). For lower risk, your doctor may recommend starting on a lower dose (such as Lipitor 20 mg/day) and increase as needed. If your doctor feels that the statin is not working, he or she may add other drugs. For example, Zetia (ezetimibe) lowers cholesterol but has not been shown to prevent heart attacks when given by itself, but it has a very slight additional preventive benefit in very high risk patients when added to statins. Evolocumab and other PCSK9 inhibitors lower cholesterol when added to statins and reduce heart attack rate very slightly in very high risk patients (N Engl J Med, 2015;372(16):1500-1509), but these drugs are incredibly expensive. Niacin lowers triglycerides but has not been shown to prevent heart attacks, even when added to statins. Besides being ineffective, niacin has a lot of unpleasant side effects(N Engl J Med, 2014;371(3):203-212).

If you suffer side effects from statins, you can try another statin or better still, stick to your lifestyle changes with no cheating. Many motivated patients can be treated with strict lifestyle changes and do not need to take drugs. People who have had a heart attack and those who are unable to reduce their risk factors with lifestyle changes probably need to take statins. Discuss your situation with your doctor.

When to Take Statins
A review of 11 articles with 1034 participants showed that taking short-acting statins in the evening lowered LDL and total cholesterol more than taking them in the morning. Time of taking a statin had no effect on triglycerides or the good HDL cholesterol. It makes no difference when you take long-acting statins (J of Clin Lipidology, June 14, 2017).

A review of 12 studies including 1023 patients showed that there was no statistically significant difference in benefits or side effects between alternate-day and daily regimens for both fluvastatin and pravastatin (Cardiovasc Drugs Ther, July, 24, 2017).

Benefits and Side Effects of Statins
For every 10,000 patients treated with statins for five years, statins possibly prevented 1000 heart attacks in people who had already had a previous heart attack and 500 heart attacks in those who were at high risk for heart attacks (Lancet, 2016;388(10059):2532-2561). The side effects in these 10,000 patients were:
• One case of rhabdomyolysis (muscle cells bursting that can damage your kidneys and kill you)
• Five cases of muscle damage
• Seven hemorrhagic strokes
• 75 new cases of diabetes
It is established that all statins can raise blood sugar levels.

Statins and Exercise
More than 20 percent of people on statins may develop muscle aches and the more you exercise, the more likely you are to suffer muscle pain and damage. Since the heart-attack-protective benefits of exercise are well established, a statin drug that prevents you from exercising can possibly increase your risk for a heart attack. A study in mice showed that those on statins moved less and did not gain the enlarged muscles and increased endurance that the mice not on stains did when they exercised (PLOS One, December 2016). The mice on statins stopped running earlier, ran far fewer miles, and lost grip strength which indicated muscle weakness and pain.

My Recommendations
It is established that statins help to prevent heart attacks in some people. Together, you and your doctor should decide whether you need to take statins, but I believe that everyone should follow the rules for healthful living. We would have far fewer heart attacks and save a lot of money. Last year people paid more than 40 billion dollars for statin drugs. Pfizer’s Lipitor was the world’s top-selling drug with annual sales of more than 12 billion dollars, and the new cholesterol-lowering drugs are expected to eventually cost more than 120 billion dollars a year.
Statins and muscle pain
Statin guidelines

Checked 7/10/21