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If you have high cholesterol that you can't lower through diet and exercise, statins may be your best hope for avoiding a heart attack. These medications -- including lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), and atorvastatin (Lipitor) -- can lower your LDL ("bad") cholesterol by 30 percent to 50 percent. Combine those impressive numbers with the fact that statins are relatively safe and easy to take, and it's no wonder they're the most frequently prescribed cholesterol-lowering medications in the United States.

Statins can help patients at several different stages along the road to a heart attack. A five-year Air Force study of 6,605 men and women with moderately high cholesterol and no sign of coronary heart disease found that lovastatin cut the risk of fatal heart attacks by about 30 percent. The drugs are even more valuable for patients who already have coronary heart disease. A five-year Scandinavian study of 4,444 men with the disease found that simvastatin reduced fatal heart attacks by more than 40 percent.

Ideally, everyone should have an LDL level of less than 100 milligrams per deciliter, and an HDL (or "good" cholesterol) level of 40 or above. However, many people fall short. If you have at least two other risk factors for heart disease -- if you smoke, have high blood pressure, have a family history of heart disease, or you're a man over 45 or a woman over 55 -- you should make sure your levels of LDL and HDL are optimal. In fact, if you have multiple risk factors, diabetes, or have already been diagnosed with coronary heart disease, your LDL cholesterol level should definitely be under 100 mg/dL, even if you need drugs to get there.

Many people can reach these goals simply by sticking to a low-fat diet and getting regular exercise . But according to a report in the June 1, 2000 issue of American Family Physician, nearly 13 million Americans have turned to some form of drug treatment to control their cholesterol.

According to the latest guidelines from the National Cholesterol Education Program, the first line of defense against high cholesterol is still a change in lifestyle -- getting regular exercise, eating a low-fat, high-fiber diet, and if necessary, losing weight. But for people who are at high risk for heart attacks, or for those whose LDL levels don't budge after a program of prescribed lifestyle changes, the NCEP recommends more aggressive action. In 2004, the NCEP issued new guidelines recommending drug therapy for high-risk individuals with LDL levels of 100 mg/dL or higher. The organization also recommends cholesterol-lowering drugs for people with coronary heart disease and for those whose HDL cholesterol level is at 40 or below. Drug therapy to reduce LDL cholesterol to below 70 mg/dL should be considered for those at "very high" risk for heart attacks, such as people who already have heart disease plus multiple risk factors such as diabetes, smoking, or high blood pressure.

A 2004 report by the American Heart Association also strongly recommends that all women who are at high-risk (more than 20 percent chance) for having a heart attack take cholesterol-lowering drugs, preferably statins, even if their LDL is below 100. To find out if you are at low-, intermediate-, or high-risk for a heart attack, use the American Heart Association's risk assessment tool .

See your physician if you're concerned about your cholesterol numbers because he or she may recommend cholesterol drugs for you even if you don't think you're at risk. That's because the NCEP recommends cholesterol-lowering drugs for people who have one or no risk factors, but whose LDL cholesterol is 190 or above. Drug therapy may also be indicated for people who are at low to moderate risk for heart attacks and have LDL levels between 160 and 189.

If your LDL cholesterol is over 220 mg/dl, your doctor will probably prescribe a statin (or other cholesterol lowering drug) right away.

If your risk is low, there's probably no need to rush into medications. But if your LDL cholesterol ever climbs above 190 mg/dl after six months of healthy eating, it may be time to try a medication. People with at least two other risk factors who are deemed to be at "moderately high-risk" for a heart attack may be advised to take a statin or similar drug if their LDL is between 100 to 129 mg/dL, despite a healthy diet.

Compared with other cholesterol-lowering drugs, statins have a good safety record and are easy to take. In several studies, patients taking sugar pills (placebos) reported as many side effects as patients taking statins.

Still, no drug is risk-free, and there are some things to watch out for. A muscle-wasting disease known as rhabdomyolysis has been reported in patients taking rosuvastatin (Crestor), and in 2005 the Food and Administration announced that it would revise the drug's label to reflect that risk. The FDA is also evaluating data that suggests people who take Crestor may be at a higher risk of kidney disease. For these reasons, the consumer watchdog group Public Citizen recommends that people not take Crestor if other alternatives are available.

Another drug, cerivastatin (Baycol), has been pulled off the market because of reports of muscle destruction linked to 31 deaths in the United States. Bayer, Baycol's manufacturer, has advised physicians to take patients off Baycol and switch them to an alternative cholesterol-lowering drug. If you're taking Baycol, talk with your doctor promptly about switching to a different statin. You should also stop taking the drug and call your doctor IMMEDIATELY if you develop a change in gait or feel listless, develop a fever, or notice any unusual pain, weakness, or tenderness in your muscles, particularly in the back and calves. If you're taking Baycol with the cholesterol drug gemfibrozil (Lopid), you should stop taking Baycol immediately and call your doctor.

In some cases, statins besides Baycol and Crestor have been linked to the muscle-wasting disease, so always get medical help IMMEDIATELY if you experience unusual pain, weakness, or tenderness in your muscles, particularly in your back or calves.

About one out of 100 patients develops high liver enzymes -- a sign of liver inflammation -- while taking a statin. Fortunately, your liver starts functioning normally again once you stop taking the drug. Your doctor will check your enzymes before prescribing a statin and from time to time afterwards to make sure your liver isn't inflamed. To further protect your liver, you should go easy on alcohol or avoid it completely while taking a statin.

Statins can interact in dangerous ways with several other drugs, including the anticoagulant warfarin (Coumadin); macrolide antibiotics like erythromycin and clarithromycin; and the transplant drug cyclosporine. Combining statins and cholesterol drugs like gemfibrozil (Lopid) and niacin (Nicolar) may also cause serious interactions. Be sure to tell your doctor or pharmacist if you're taking these or any other medications, and ask for a list of drugs that it can interact adversely with.

As with many other medications, it's wise to avoid drinking grapefruit juice while taking a statin. (Grapefruit juice contains ingredients called flavonoids, one of which has a strong effect on the metabolism of certain drugs.)

All of the statins can provide powerful protection for your heart, but some may be better choices than others. If your LDL is extremely high, your doctor may want to prescribe either simvastatin or atorvastatin, the two most powerful drugs in the class. Fluvastatin, the least expensive drug, may be a good option if you need to make a minor dent in your cholesterol. Small doses of atorvastatin are another inexpensive option for slightly above-normal cholesterol.

Statins aren't the only medications that can improve your cholesterol levels. If your HDL ("good") cholesterol is too low, your doctor may prescribe niacin instead of -- or in addition to -- a statin. While statins can slightly increase your HDL, niacin will give it a much bigger boost. Likewise, you may need a fibrate drug such as gemfibrozil if your triglycerides (another type of fat in the blood) are too high. Both niacin and fibrates tend to cause more side effects than statins. As your doctor which side effects you can expect.

In addition, since combining certain statins with niacin or gemfibrozil can be harmful, contact your doctor immediately if you develop a change in gait or muscle weakness, tenderness, or pain.

For the best protection against a heart attack, you may have to keep taking a statin for the rest of your life. At the very least, you should take the drug until your doctor says it's okay to quit.

Unfortunately, many patients set aside their prescription bottles without telling their doctor. It's easy to "forget" to take a pill when it doesn't make you feel any better. But remember: Heart disease can work silently, too. No matter how good you feel, sticking to your prescription just might save your life.

-- Chris Woolston, M.S., is a health and medical writer with a master's degree in biology. He is a contributing editor at Consumer Health Interactive, and was the staff writer at Hippocrates, a magazine for physicians. He has also covered science issues for Time Inc. Health, WebMD, and the Chronicle of Higher Education. His reporting on occupational health earned him an award from the northern California Society of Professional Journalists.

References

First published May 23, 2001
Last updated January 18, 2007
Copyright © 2001 Consumer Health Interactive

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