It is established that having a high bad LDL cholesterol increases your chances of suffering a heart attack (Int J Environ Res Public Health, Jul, 2022;19(14):8272; Lancet, Nov 21, 2020;396(10263):1644-1652) and that reducing high levels of LDL helps to prevent heart attacks (Lancet, Aug 11, 2012;380(9841):581–590). Statins are the most used drugs to treat high cholesterol, but about 75 percent of people suffer muscle pains and other side effects when they take statins (Cureus, Mar, 2022;14(3):e23463). Simvastatin is most likely to cause muscle pain, while fluvastatin and rosuvastatin may be least likely. Possible side effects of statins include headaches, nausea, muscle and joint pains, and less commonly, increased blood sugar levels, muscle damage, liver damage or loss of memory.

Suggested regimens for taking statins for people who suffer muscle pains and other side effects include: every-other-day atorvastatin or rosuvastatin, or twice-weekly rosuvastatin. These regimens are not approved by the FDA. Some people recommend CoQ10, red rice yeast or vitamin D, but these supplements are controversial and we have no strong evidence that they help.

Reasons for Starting Statins
• If your total cholesterol is greater than 200 mg/dL (5.2 mmol/L)
• If your bad LDL cholesterol is greater than 100 mg/dL (2.6 mmol/L)
• If you have had a heart attack or have a number of heart attack risk factors. Risk factors for a heart attack include smoking, not exercising, high blood pressure, diabetes, overweight, having narrowed arteries near the heart or in the neck, arms or legs, a family history of heart attacks, and age over 65.

Other Drugs to Lower LDL Cholesterol
• Ezetimibe helps prevent your small intestine from absorbing cholesterol and is one of the few non-statin medications that can lower LDL cholesterol levels even more when combined with a statin. It can be combined with other statin alternatives and has few side effects.
• Fibrates like gemfibrozil mildly lower LDL cholesterol and triglycerides, a major risk factor for diabetes. They can be used with a statin or ezetimibe.
• Bile acid sequestrants such as cholestyramine (Prevalite), colestipol (Colestid), and colesevelam (Welchol). Bile acids are made in the liver and pass to your intestines to help digest and absorb fats. Bile acid sequestrants reduce absorption of bile and cholesterol. They can raise blood triglycerides and cause constipation.
• Omega-3 fatty acids, such as Lovaza and Vascepa, can be taken with statins and help to lower triglycerides.
• PCSK9 inhibitors (Praluent, Repatha) are injected once or twice a month to block a liver enzyme called PCSK9 that prevents the liver from breaking down cholesterol. They may be prescribed when a combination of statins, ezetimide and lifestyle changes have failed to lower cholesterol adequately.
• Inclisiran (Leqvio) blocks production of the PCSK9 enzyme. It is injected once every six months.
• Bempedoic acid (Nexletol) and bempedoic acid/ezetimibe (Nexlizet) block an enzyme in the liver that makes cholesterol. They may be prescribed when other drugs fail to lower cholesterol.

Lifestyle Changes to Help Prevent Heart Attacks
• avoid all sugared drinks including fruit juices
• severely restrict all sugar-added foods and other refined carbohydrates
• restrict fried foods
• avoid red meat (blocks insulin receptors)
• avoid processed meats
• avoid smoking and being around smokers
• avoid alcohol or take no more than one drink a day
• lose weight if overweight
• eat a wide variety of vegetables, fruits, whole grains, beans, nuts and other healthful plant-based foods
• keep hydroxy vitamin D above 30 ng/mL
• exercise

My Recommendations
If you have blood levels of the bad LDL cholesterol greater than 100 mg/dL, or several heart-attack risk factors, your doctor will definitely recommend certain lifestyle changes that help to prevent heart attacks. They may also recommend that you take statin drugs to lower your heart attack risk. If your LDL cholesterol does not drop low enough or you have significant side effects from statins, your doctor can prescribe some of the other drugs listed above to add to or replace the statin drug.