Each day, 47 million Americans take cholesterol medication—and usually it’s a statin, a pill that has a powerful impact on keeping the heart healthy. When there is too much of a waxy substance (called cholesterol) in the blood, a statin can help to clear it away and reduce the amount the liver can make. This keeps the cholesterol from leaving fatty deposits (called plaque) in the arteries, greatly reducing the risk of heart attack or stroke.
However, taking a statin can be a complicated choice. Many people find the potential side effects concerning or think they’ll have to take the statin for the rest of their lives. Others prefer to try to fix the problem with diet and exercise.
“We know that if you have heart disease, specifically atherosclerosis, statins, if tolerated, are an absolute must,” says Brian Cambi, MD, a Yale Medicine cardiologist. “As far as who should take statins for prevention, that continues to get refined.” Many studies have shown statins are safe, effective, and beneficial for multiple segments of the population, he adds.
“If your doctor does recommend a statin, it’s important to understand why,” says Yale Medicine cardiologist Erica Spatz, MD, MHS. “We want to identify people who will benefit most from a statin and bring them into the decision-making process. Many people never fill the prescription or abandon the therapy because the doctor may not have had those discussions with them.”
Patients often don’t know why they are taking a statin and end up discontinuing what is supposed to be a lifelong therapy, she adds.
If you have high cholesterol, making an informed choice also may require assessments and medical tests beyond a lipid profile (or “lipid panel”)—the blood test that measures cholesterol levels—often, the first clue that your levels are on the rise.
Below, Drs. Cambi and Spatz answered common questions about statins.
1. What is cholesterol, and why might you need a statin for it?
Cholesterol is the offending agent in atherosclerosis, a condition that develops when cholesterol, fat, blood cells, and other substances in the blood create plaque in the arteries. The waxy, fat-like substance can accumulate in the middle layer of the vessel wall, inciting an inflammatory reaction. “Over time, inflammatory debris can grow and ultimately encroach on the part of the vessel where blood is flowing, obstructing that blood flow,” Dr. Cambi says. That can cause chest pain and lead to heart attacks and strokes.
There are two kinds of cholesterol: blood cholesterol, which is made by the liver and necessary for performing such tasks as digesting fatty foods and making hormones, and dietary cholesterol, which is found in animal foods, including dairy products, eggs, meat, poultry, and some types of seafood.
Reducing dietary cholesterol can sometimes bring it down to normal levels, but diet alone isn’t effective for everyone. “Genetically speaking, some of us make more cholesterol than others, and some of us have blood vessels that absorb more cholesterol than others,” Dr. Cambi says. So, it can be a surprise for some to learn that they have high cholesterol even though they exercise regularly and eat a healthy diet.
2. How do you know if you have high cholesterol?
High cholesterol rarely causes symptoms, but a lipid profile can show whether you have it and how serious it might be. This blood test usually involves avoiding food and drinks other than water for 8 to 12 hours. (The test measures cholesterol in milligrams per deciliter of blood [mg/dL] to show the concentration of the cholesterol in a specific amount of blood.)
Lipid profile results for adults 20 and older include the following measures:
- HDL (high-density lipoprotein) cholesterol: This is known as “good” cholesterol because it moves extra cholesterol in the bloodstream to the liver, which dispenses it from the body. A healthy level for women is 50 mg/dL or higher; for men, it is 40 or higher.
- LDL (low-density lipoprotein) cholesterol: It’s also called “bad” cholesterol because it blocks the good HDL and contributes to plaque buildup in the artery walls. A healthy result is less than 100 mg/dL.
- Total cholesterol: This is all the cholesterol in your blood, including both LDL and HDL. A healthy range is 125 to 200 mg/dL.
- Triglycerides: The body converts calories it doesn’t use immediately into triglycerides and stores them in the cells. Triglycerides tend to be higher in people with high cholesterol, heart problems, obesity, and diabetes. A healthy number is less than 150.
The Centers for Disease Control and Prevention (CDC) recommends most healthy adults have their cholesterol checked every four to six years, and more often if they have heart disease, diabetes, or a family history of high cholesterol.
3. How do statins work?
Statins (medically known as HMG CoA reductase inhibitors) work in the liver, inhibiting an enzyme (a substance that acts as a catalyst in organs) important in cholesterol synthesis. As a result, the liver makes less cholesterol and pulls in the cholesterol found in the bloodstream, Dr. Cambi explains.
Looking at it another way, “statins do three things,” Dr. Cambi says. “One, they lower the amount of bad cholesterol in the bloodstream that can be deposited in the arteries. Two, almost all of us have some amount of plaques, and statins stabilize the covering [what’s called the fibrous cap] over these plaques, rendering them less likely to rupture, thereby decreasing the chance of an unstable plaque or a heart attack. Three, statins put up theoretical ‘roadblocks’ in the vessel wall, helping to prevent cholesterol from being deposited in its lining.”
Statins also reduce heart attack and stroke through other non-cholesterol effects, Dr. Spatz says. “They have anti-inflammatory and antioxidant effects.”
4. How well do statins work?
Statins can lower cholesterol by as much as 30% to 50%, according to some sources. This is a better result than any other drug that has been used for reducing cholesterol. “Researchers worked for years to develop medicines to lower cholesterol in the body before the first statin was introduced in the 1980s,” Dr. Cambi says, adding that they were the first drugs to show an ability to reduce “a hard endpoint,” such as a reduction in death or heart attack or stroke.
Since then, an abundance of research has shown that statins are effective. In fact, “statins are among the most studied cardiovascular medications,” says Dr. Cambi. “There have been studies looking at people who just have high cholesterol, those with multiple risk factors for heart disease, and those who have already had a heart attack or stroke. All of this work has shown the benefits from statins to be durable and reproducible.”
5. What are the arguments against statins?
One concern is statin side effects. Some people report muscle pain and weakness, which has been shown to affect about 10% to 15% of people who take statins. But Dr. Spatz believes the figure is closer to 5%, especially if you consider the “nocebo” effect—a negative reaction in a patient who had negative expectations for a treatment, she explains. “People hear reports about muscle aches and become hypervigilant about that kind of symptom,” she says.
Some research has shown that statins increase blood sugar. “Statins can increase blood sugar by a small amount,” says Dr. Spatz. “For some people who are just on the margin of being diagnosed with diabetes, that can make the difference. However, it’s also true that if they already had elevated blood sugars and are now classified as having diabetes, there's more benefit to be derived from the statin medicines because having diabetes puts them at higher risk for cardiovascular diseases.”
Yet another concern is that once you take a statin, you must remain on it, which Dr. Cambi says is not the case. “If you have heart disease, it would be my recommendation to be on a statin lifelong,” he says. “But it’s not dangerous to stop. There are medicines where you may have withdrawal or a rebound if you stop them suddenly. That's not the case with statins.” But if, say, a person’s high-fat diet contributed to high cholesterol, and they don’t change their diet, their levels are likely to go back up if they stop the statin, he adds.
6. What do women need to consider with statins?
Dr. Spatz says that women historically have been considered at low risk for heart disease and, as a result, are under-prescribed preventive medications. For that reason, it may be especially important for women to talk to their doctors about statins, especially if they have heart disease risk factors, she says. If they are of childbearing age, Dr. Spatz also recommends patients bring up any history of preeclampsia (a condition in pregnancy characterized by high blood pressure and other symptoms), early menopause, and any other heart disease risk factors that could change the value equation for taking a statin.
Women may find it’s more important to monitor their cholesterol levels during and after menopause, when the risk of plaque narrowing coronary arteries increases, Dr. Cambi adds. “Women's endogenous estrogen is often cardioprotective in their younger years,” he says. “But after menopause, a woman's risk for heart disease quickly escalates to that of a man of the same age.”
7. What other factors should go into a decision to take a statin?
In 2022, the U.S. Preventive Services Task Force (USPSTF) recommended anyone ages 40 to 75 consider a statin if their risk of developing atherosclerosis within the next decade is 10% or greater. A doctor can start to determine a person’s 10-year risk using a cardiovascular disease risk calculator, which considers factors such as gender, race, blood pressure, smoking history, diabetes, and age.
Discussion beyond the calculator results is also important, Dr. Spatz says, adding that 10-year calculators don't take into account such important factors as family history.
Furthermore, according to the CDC, a doctor may prescribe statins if:
- You have already had a heart attack or stroke, or have peripheral arterial disease.
- Your LDL cholesterol level is 190 or higher (this is the one lipid profile result where you might base a statin decision on the lipid profile alone).
- You are 40–75 years old and have diabetes and an LDL cholesterol level of 70 or higher.
- You are 40–75 years old, have a high risk of developing heart disease or stroke, and an LDL cholesterol level of 70 or higher.
In some cases, medical tests can provide helpful information. For instance, a calcium score test involves a noninvasive CT scan that assesses the amount of calcium in a person’s coronary arteries. The presence of calcium (a component in plaque) may tip the balance toward a decision to take a statin.
8. Can lifestyle changes bring down your cholesterol?
When a person’s cholesterol numbers are out of the recommended ranges, but their 10-year risk is moderate, a doctor may suggest making lifestyle changes and repeating the lipid profile in a few months to see if there is a change. A lifestyle overhaul should include switching to a heart-healthy diet focused on fruits, vegetables, whole grains, legumes, nuts, fish, and poultry. Many refer to this as a Mediterranean-style or (for vegetarians) a whole-food, plant-based diet.
Patients also can increase physical activity, eliminate tobacco, and limit alcohol, as well as manage their weight and conditions like diabetes. Such lifestyle changes are important even if you take a statin, Dr. Cambi says.
If these changes don’t eliminate the need for a statin, it may suggest the appropriateness of a lower dose. “Success may depend on the patient’s starting point,” Dr. Cambi says, explaining that those who make major life changes tend to have the most dramatic results.
9. If you decide to take a statin, which one should you choose?
There are many choices, including tablets and capsules, different brands, less-expensive generic options, and options with varying levels of effectiveness.
Two medications, rosuvastatin (Crestor®) and atorvastatin (Lipitor®), “are by far the most common, most studied, and most used statins,” Dr. Cambi says. Other statins aren’t as potent but are still used by some patients who find them to be the most tolerable for them, he says.
10. What can you do if you can’t take a statin?
Statins don’t work for everyone—some people have difficult side effects, or their statins aren’t effective; others are allergic to them. Some newer drugs have been shown to lower cholesterol levels, as well as the risk of heart attack and death. Those medicines include monoclonal antibodies (laboratory-made proteins that act like human antibodies in the immune system to fight disease), among others.
“Most of the studies on the newer drugs have been done on people who were on a maximally tolerated statin dose, and they are usually prescribed in addition to a statin,” Dr. Spatz says. “There are some people who can only tolerate a minimum dose of a statin or no statins at all, and in those cases, we might prescribe these newer drugs as an alternative.”
11. What questions should you ask your doctor about statins?
“You should ask the doctor to help you understand the rationale behind putting you on the medicine,” Dr. Cambi says. “Medicine is becoming a more personalized service and that can help with statins. We have tools that allow us to learn about a patient’s unique characteristics to the point where we can tailor a medical regimen that's specific to them.”
Dr. Spatz says patients should talk to their doctor about anything on their mind regarding a statin. The more they understand about the medication and their own health, family history, and risks for heart disease, the more likely they will be to make the right choice—and the chances are better they will keep taking the medicine if that’s what they choose.
“A statin medication is always a shared decision, even in people who have established disease,” she says. “If people understand the evidence and some of the trade-offs, they can make their own decisions. Often, people choose well for themselves.”