Heart Disease Case Study: To Statin or Not to Statin

Karly, age 66, was reminded at her routine wellness checkup this year that all women are at risk for cardiac disease after menopause. She was told at her visit she had high cholesterol. Her total cholesterol (TC) and low-density cholesterol (LDL-c, the “bad” cholesterol) had both skyrocketed during the previous twelve months. Her high-density level cholesterol (HDL-c, the “good” cholesterol) also increased, but the 250 mg/dL total cholesterol was well above recommended levels with implications for future cardiac disease risk. Now what?

The American Heart Association recommends lifestyle interventions as the first line of defense for reducing the risk of cardiac disease in otherwise healthy individuals. Maintain a healthy weight, get regular aerobic exercise, quit smoking, drink less alcohol, reduce your stress, and try to eat healthy meals most of the time. Lifestyle interventions are most effective when started early and have been shown to reduce markers of cardiac disease such as cholesterol, blood pressure, triglycerides, and glucose levels. Sometimes the first line of defense is not enough. Karly already followed a healthy lifestyle with no history of pre-existing cardiac or metabolic disease. Her only risk factors were non-modifiable: age, gender, and menopause status.

The second line of defense is medication, most often a statin drug. There are several types of statins that work differently in the body; all can be effective in reducing cholesterol and LDL-c levels when lifestyle interventions are inadequate. Statins are frequently misunderstood, and many are afraid to use them. Rare side effects include rhabdomyolysis, which is a dangerous breakdown of proteins in muscles, however, that occurs in less than 1% of users. Studies suggest statins contribute to a small increased risk of diabetes in some adults, however, the greatest risk is in users taking high doses of statins with other comorbidities that predispose them to diabetes. The most common side effect of statin drugs is joint pain which may be alleviated when switching to another type of statin or adding Coenzyme 10 dietary supplements.

Statins work by keeping arteries supple and flexible. They lower LDL-c and TC levels. Arteriosclerosis is commonly referred to as “hardening of the arteries” and is exactly what it sounds like. Estradiol has a protective effect in premenopausal women against the development of cardiac disease, but estradiol levels post-menopause decline, predisposing all women to cholesterol buildup within their arterial walls. That causes stiffening and narrowing of the arteries. The blood pumped from the heart is forced through a narrower less flexible artery, increasing pressure and risk for aneurysms, strokes, and heart attacks. The American Diabetes Association, the American Heart Association, and the American College of Cardiology all strongly recommend a statin for any woman between the ages of 40 and 75 with diabetes because of the drug’s proven benefits in reducing the risk of heart attack, stroke, and peripheral vascular disease.

What about the benefits of statins in postmenopausal women without diabetes who develop high cholesterol, like Karly? The American College of Cardiology/American Heart Association guidelines for treatment is based on the individual’s ASCVD (atherosclerotic cardiovascular disease) 10-year risk. Risk factors include age, sex, race, total cholesterol, HDL-c, systolic blood pressure, and whether you are receiving treatment for hypertension, have diabetes, or are a smoker.

Here is an online calculator you can use to check your own risk.

Karly had a low-risk ASCVD profile, so she could have adopted a wait-and-see approach prior to starting statins. Her physician recommended a low dose statin because her cholesterol jumped quickly without recent changes in lifestyle.  Because women metabolize medications, including statins, differently than men, she chose to try a very low dose of a newer statin, rosuvastatin (Crestor), and will closely monitor for side effects. It’s an individual decision, so be informed of the facts!