Heart disease is the leading cause of death among adults in the United States, and high levels of cholesterol can increase your risk. Meanwhile, both heart disease and high cholesterol can also raise your likelihood of having a stroke.
If you have high cholesterol, your healthcare provider (HCP) may prescribe you cholesterol-lowering medications, such as statins, to reduce your risk of complications. They may also recommend lifestyle interventions, like eating a healthy diet and getting regular physical activity.
Lifestyle changes can be beneficial, whether you have high cholesterol or not. Statins, however, are used only in specific cases.
Rakesh Shah, MD, a cardiologist with Clear Lake Regional Medical Center in Webster, Texas, sheds light on prescribing guidelines for statins, side effects, and more.
What you should know about cholesterol
Cholesterol is a waxy substance found naturally in our cells. Our bodies need it for many functions, such as hormone production and digestion. But too much—or an abundance of the “bad” kind—can build up in the arteries and increase the risk of heart attack and stroke.
There are two main types of cholesterol. Low-density lipoprotein (LDL) is the “bad” kind of cholesterol that can build up in your arteries. High-density lipoprotein (HDL) is the “good” kind that carries excess cholesterol to the liver, where it's removed from the body so it doesn’t get stuck to blood vessel walls.
Your body makes all the cholesterol it needs for essential functions, so you don't have to worry about getting it in your diet. In fact, the cholesterol you get from food has little effect on the cholesterol in your blood. That said, many high-cholesterol foods, such as red meat, full-fat cheese, and certain vegetable oils such as coconut oil and palm oil are also high in saturated fat, which has a much more significant impact on your cholesterol levels.
To figure out your cholesterol levels, your HCP will take a blood sample and have it tested at a lab. The results will help your HCP determine your risk of having heart disease or a stroke within the next 10 years, which will guide the decision of whether you should take cholesterol-lowering medication.
Recommendations for cholesterol screenings vary, but the American Heart Association (AHA) suggests most people get their levels tested every four to six years beginning at age 20. It's best to speak with your HCP about the screening schedule that makes the most sense for you, based on your health profile.
Lifestyle modifications to try
If a routine screening reveals higher-than-normal levels of blood cholesterol, your HCP will likely prescribe a course of treatment.
In clinical practice, attempting to lower cholesterol by tweaking your daily habits is always the first goal, according to Dr. Shah. "Lifestyle modifications are the number one treatment for any medical problem, including high cholesterol," he says.
Your HCP will likely advise you to adopt a healthy diet and a regular exercise regimen. Specific strategies may include:
- Limiting saturated fat to 5 or 6 percent of your daily calorie intake
- Adopting the DASH diet, which is designed to lower high blood pressure, but benefits overall heart health, as well
- Increasing the amount of walking you do during the day—to work, at the office, during your lunch break, etc.
If you smoke, they will encourage you to kick the habit.
“Depending on your initial level of cholesterol, you may be able to lower your levels enough to avoid taking medication," Shah says.
When your HCP may prescribe a statin
If these tactics fail to reduce cholesterol to a level your HCP deems acceptable, however, they may prescribe a statin.
Research suggests that lowering cholesterol with statins can reduce the risk of stroke and heart attack. Statins do this by preventing additional plaque buildup in blood vessels and restoring function of the endothelium. The endothelium is the thin lining of the heart and blood vessels that helps control blood clotting and vessel relaxation and contraction.
Other cholesterol-lowering medications can be prescribed, but statins are often the drug of choice. "Statins have conclusively been shown to prevent heart attack and stroke," Shah says.
Not everybody needs a statin, however. Only between 30 and 40 percent of Shah’s heart patients have been prescribed statin medications for one reason or another.
Your HCP will decide if you need a statin based on your:
- Age
- Ethnicity
- Cholesterol level
- Blood pressure
- History of smoking
- History of medical conditions like kidney disease, psoriasis, premature menopause, or preeclampsia
- Family history of heart disease
- Other individual risk factors for heart disease.
If additional information is needed, your HCP may order a heart CT scan or another imaging test called a coronary artery calcium (CAC) test for people between the ages of 40 and 75. Because calcium is a part of the plaque that builds up in your arteries, the CAC test enables your HCP to help identify and measure plaque.
The results of your CAC test can help your HCP determine if you’re at risk for heart disease even before you develop signs or symptoms. (Note that the calcium in your heart’s arteries is different from the calcium in your bones and isn’t directly related to how much calcium is in your diet.)
The goal for patients with a history of heart attack, stroke, or arterial disease in the legs is to reduce cholesterol by at least 50 percent using statin medication, according to Shah. "It doesn't matter what their initial cholesterol level is, we try to reduce them by half for the maximum benefit," he says.
Statins have some side effects
Statins are typically well-tolerated when taken to control high cholesterol. Adverse reactions are less common among people taking these drugs than with other cholesterol-lowering medications. But they're not entirely without side effects.
"Anywhere from 5 to 25 percent of patients will report side effects," Shah says. "The most common ones we encounter are muscle and joint discomfort," which can range from a dull soreness to excruciating pain.
You may also experience weakness that can make climbing stairs, rising from a seated position, and lifting your arms a challenge. The onset of symptoms usually happens within a few weeks or months of beginning statin therapy, but can occur at any time during treatment.
Don't hesitate to speak with your HCP about side effects that bother you or won't go away. Muscle pain is usually bearable but can be relieved if necessary by changing the dose or switching to a new type of statin.
Also talk to your HCP about side effects like fatigue, weakness, loss of appetite, or yellowing of the skin. These could signal liver problems. Allergic reactions can include swelling of the face, lips, tongue, and throat and difficulty breathing or swallowing, which may require immediate medical attention.
The bottom line on statins
Despite the potential downsides, Shah believes statins are generally worth taking for certain patients. “When we prescribe statin medication, the benefit outweighs the risk of having side effects,” he says. “It's always good to follow your doctor's advice."
If statins are ineffective, or if the side effects are intolerable, your HCP may recommend a newer cholesterol-lowering drug, such as a PCSK9 inhibitor. It helps the liver remove more LDL cholesterol from the blood and limits the amount of plaque that can build up in the artery walls.
Another drug, ezetimibe, is also available and typically added to statin therapy when more LDL reduction is needed. It works by preventing the absorption of cholesterol in the intestine. Bempedoic acid, which targets a specific liver enzyme and was approved by the U.S. Food and Drug Administration (FDA) in 2020, may also be combined with statins in certain cases. Your HCP will be your best resource to help determine which medications are right for you.
Ultimately, it’s vital to ask questions, voice concerns, and work with your HCP to create a cholesterol treatment plan that keeps your health on track while letting you live your best life.
