The Doctor Weighs In

Bill Bestermann

Whenever a commercial runs on television and the topic is a statin drug, there is a long rendition of potential side effects.  There are warnings that you should report muscle pain or weakness and that you should have tests to check your liver.  Certainly, reasonable caution is prudent with any medication but one of the main reasons you see a doctor is to have a knowledgeable, wise person help you consider the risks and benefits of a potential treatment.  When it comes to risks and benefits, there is no happier story in all of medicine than the statin drugs in lowering cholesterol.

These medications are very powerful.  In South Carolina, where I practiced for 30 years, roughly half of the population dies of vascular events.  In the early part of my career I admitted a very large number of patients to the hospital with heart attacks and strokes.  Far too many of them died.  We just did not have very much that worked very well.  When I entered medical school, I was performing calculations with a slide rule.  It is hard to realize just how much the world has changed and the medical world has changed technically as rapidly as any professional field.  The statin drugs are one of the most amazing technical developments.   

The statin drugs do have very real side effects.  Here is the big picture.  I have admitted hundreds of patients to the hospital with problems caused by arterial disease.  Many of them died.  I have admitted one patient to the hospital with a cholesterol therapy complication-and he walked out of the hospital.  The television commercials on statin therapy warn of liver problems.  If you compare a million patient-years of statin use with a million patient-years of no statin use-there is no difference in the number of serious liver problems.  I have never admitted anyone with a statin-related liver problem.  There is an issue of muscle pain or weakness.  The incidence of muscle pain or cramps may be from 1%-5%.  But the problem is that so many patients who are at risk have aches and pains anyway.   The pain that goes with statin muscle injury is like the flu—it is all over the body—it is diffuse.  If you think you are weak but you can get out of a chair without using your arms to push up—you probably do not have a significant statin myopathy.   Significant muscle injury can be detected by measuring a CPK lab test.  Muscle injury occurs more frequently when statin drugs are used in combination with other medications that cause the level of the statin drug to increase.  Many times we can get around the muscular complaints by changing the drug or the dose.  Only one in 10,000 patients treated with a statin develops the serious muscle injury called rhabdomyolysis.

These medications have a very powerful effect in preventing cardiovascular events.  Statin therapy alone reduces coronary mortality by 42% and combination therapy (statin plus niacin) aimed at abnormal lipids may lower vascular events by as much as 90%.  These effects are almost immediate, extremely potent, and very impressive.  If a single dose of a statin drug is given to a laboratory animal prior to the creation of an experimental infarction, the
size of that infarction is reduced by half.  That is important news because it is the size of the infarction that determines the likelihood of most of the adverse outcomes of the heart attack including congestive heart failure-the number one cause of hospitalization for Medicare patients.

Bench science with rats sometimes does not extend to humans, but data from the National Registry of Myocardial Infarction suggests that we can extend this concept to patients.  There were 300,823 patients in the registry reporting to the emergency room with an acute heart attack.  Myocardial infarction victims with new or continued statin treatment during the first 24 hours experienced a mortality of 5% and those with no statin treatment experienced  a mortality of 15%.  Statin-treated patients had lower risk of cardiogenic shock, arrhythmias, cardiac arrest and rupture—all typically related to the amount of heart muscle killed by the artery blockage.

Finally, treatment with statin drugs can lead to achieving that most elusive goal in the treatment of vascular disease.  You can reverse cholesterol buildup in your arteries.  Dr Steven Nissen of the Cleveland Clinic has proved this in the Asteroid trial.  Using an intravascular ultrasound catheter (IVUS), Dr Nissen was able to show that lowering LDL cholesterol to 62 with high-dose Lipitor (atorvastatin) significantly reduced the size of the cholesterol deposit obstructing a heart artery.  When you examine the IVUS catheter trials that have looked at how the amount of plaque changes depending on the LDL level, it looks like the break point is in the mid-70s.  When your LDL is over 75 you are putting cholesterol down in the artery.  When it is less than 75, you are pulling cholesterol out and not just in that artery, but in all of the arteries in the body.

The statin medications to lower LDL cholesterol are a great addition to the tools that are available to reduce the toll of arterial vascular disease.  It is important to approach them with a positive attitude and if you think you have a side effect you need to discuss it with your doctor.  Is it really related to the statin?  Is it severe enough to warrant stopping the drug.  Can it be reduced or eliminated by changing the drug, reducing the dose, or changing other medications in the medication program.?  It is important to find a way to continue these medications if this goal can be accomplished safely—and usually it can be!

William Bestermann is Medical Director of the Vascular Medicine Center of the Holston Medical Group in Kingsport, TN. He is also President of the Cardiovascular Center of Excellence program under the auspices of the Consortium for Southeast Hypertension Control.  Click here to read his other articles on TDWI . You can reach Dr. Bestermann at whb@hmgkpt.com.