Cardiovascular disease remains the leading cause of death in the US. To help combat unnecessary deaths, national guidelines by the American College of Cardiology/American Heart Association (ACC/AHA) suggest that in addition to a healthy lifestyle, people at risk should talk with their doctors about taking ­cholesterol-lowering statin drugs. ­Research shows that these drugs help stop buildup of plaque in arteries, a main risk factor for heart attack and stroke, and may stabilize already built-up plaque.

Although statins were initially approved to reduce high cholesterol levels, the definition of “high cholesterol” has changed through the years, as has the consideration of statins for other related health concerns. In addition to those with established heart disease, statins now are recommended for people ages 20 to 75 with an LDL-cholesterol level of 190 mg/dL or higher…patients with diabetes ages 40 to 75 (have a risk-­benefit discussion with your doctor if you’re younger or older)…or with a 10-year calculated risk for heart disease of 7.5% or higher (more on this factor below). Some of these criteria are clear-cut, but others are more of a gray area. Here’s what you need to know before you say “yes” to a statin prescription.

Two Types of Prevention

When considering statins to prevent heart attack and stroke, there really are two types of prevention. Primary prevention relates to people who have never had either of these events and are trying to prevent one from happening in the first place. Secondary prevention relates to people who already have had a stroke or heart attack, which puts them at high risk for a second one in the future. 

There’s no controversy regarding the benefits of statins for secondary prevention. All people who have had a heart attack or stroke, in addition to striving for a healthy lifestyle with exercise and a healthy diet, should be taking statins. For these patients, it is a lifelong commitment as they remain at high risk for a future event.

The statin decision is more nuanced when it comes to primary prevention. The guidelines recommend them for a broader range of people than ever before due to our better understanding of risk enhancers. But the value of statins has to be evaluated in the context of your personal health history and weighed against the concern surrounding side effects, such as muscle pain or weakness, headaches and dizziness. A careful evaluation of the combined answers to three key questions can help clarify whether these statins are right for you. 

The 3 Questions

1: What is my ASCVD Risk Score? At the heart of the widening scope of who should take statins is the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator, created by the ACC/AHA and used by doctors to evaluate their patients. You can take it online at https://bit.ly/2TBlmpC.

After plugging in information—such as cholesterol (total, HDL and LDL), blood pressure, age, race, gender and whether you have diabetes or are or were a smoker—the tool rates your 10-year risk of having a heart attack or stroke. You’ll note that there are no questions about diet or exercise in this questionnaire. If you are exercising regularly and eating well, your blood pressure and cholesterol ­levels would reflect the impact of those healthful behaviors.

Results fall into four categories… 

Low: Below 5%

Borderline: 5% to 7.4% 

Intermediate: 7.5% to 19.9%

High: 20% or greater.

Interpreting the low and high scores is very easy. If you have a low score, statins generally are not recommended—you can feel reassured that you’re in good shape. If you’re at high risk, many doctors recommend starting a statin—its preventive benefits have been proven. You may be able to lower the dose over time by making healthy lifestyle changes. 

If your score is borderline or intermediate, the statin decision is more nuanced. Also, no risk calculators are perfect. In research conducted at Kaiser Permanente, we found that there was risk overestimation among adults without diabetes between ages 40 and 75, which could lead to unnecessary statin therapy. In fact, at Kaiser Permanente, we are in the process of implementing our own calculator that will address this problem. But for now, the ACC/AHA ASCVD Risk Estimator is a useful tool. 

Benefits to knowing your ASCVD Risk Estimator score: Your result can trigger a useful discussion with your doctor and encourage you to look at lifestyle habits that could help reduce your risk for heart disease. A healthy lifestyle remains the cornerstone of prevention of heart disease and stroke. Rather than starting statins, you might try to lower your risk through improved diet, exercise and, if you smoke, quitting. 

2. Do I have any “risk enhancers”? These factors increase your heart attack and stroke risk but currently are not part of the ASCVD Risk Estimator ­questionnaire…

  • Having a family history of premature heart disease—before age 55 in men…age 65 in women 
  • Having LDL cholesterol of more than 160 mg/dL
  • Having metabolic syndrome, a group of risk factors that include high triglyceride levels, high blood sugar, high blood pressure and excessive body fat around the waist
  • Having chronic kidney disease
  • Having an inflammatory condition such as rheumatoid arthritis, psoriasis or HIV/AIDS 
  • Menopause before age 40
  • Having had a pregnancy-related circulatory condition such as preeclampsia 
  • Being part of a high-risk ethnic group, such as South Asian
  • Having a biomarker such as Lp(a) (a type of low-density lipoprotein—LDL—cholesterol) levels of 50 mg/dL or higher. 

3. What is my CAC score? A low-­radiation imaging test detects the level of coronary artery calcium (CAC) buildup in your arteries. The presence of such plaque buildup is associated with risk for future heart attacks. If there is a question about the merits of taking a statin, having this test may help indicate whether you will benefit. Results are given as a number, from zero to, in some cases, more than 1,000. 

0: This shows no calcium or calcified plaque buildup so no statin would be recommended in the absence of diabetes, family history of premature heart disease and smoking. 

1 to 99: You have some degree of calcium buildup that can help guide the statin decision-making process. Having a lower number might allow you to put off statins and adopt a lifestyle of good habits. However, if you’re over age 55 and have plaque development and are at the higher end of this range despite a healthy diet and regular exercise, taking a statin merits consideration. 

100 and over: This score suggests that statin therapy should be considered. 

A recent study published in Circulation: Cardiovascular Imaging added to our understanding of the CAC score and differences in how it predicts heart attack and stroke. It found that…

  • The 10-year risk level for both heart attacks and strokes for those with scores of 1 to 99 is below 6%.
  • At scores of 1 to 99, stroke risk is higher than heart attack risk for ­women…and the reverse for men. 
  • With a CAC score of 100 or higher, the 10-year heart attack risk jumped above 12% for men and 8% for ­women. Stroke risk averaged 8%, with a woman’s risk again higher than a man’s. 

Benefits to knowing your CAC score: As a real-time snapshot, the CAC is a visual reinforcement of your risks and can help encourage lifestyle changes even if you’ve been resistant. 

If Your Doctor
Suggests Statins…

If statins seem wise for you, ask your doctor if you can take a low dose to minimize any side effects.

While natural practitioners may recommend supplements of CoQ10 and/or vitamin D to help prevent statin side effects, their effectiveness has not been demonstrated in randomized control trials. However, both have good safety profiles, so there is no harm in trying them to see if they help. 

When There’s Time to Put Off Statin Therapy

The first and foremost step in preventive cardiology is lifestyle changes—following a plant-based diet focused on vegetables, fruits, whole grains, nuts and seeds, and unsaturated fats (such as olive oil)…eating less animal protein and minimal added sugars…getting more exercise…and losing weight if needed. Losing just 5% to 10% of excess body weight can lead to significant improvement in cholesterol as well as blood pressure. 

We know these changes are more difficult than taking a pill, but remember that statin therapy is not an alternative to healthy eating and exercise—it’s an added preventive measure to consider when those steps aren’t enough.