What You Need to Know About Statins

Intro: We're talking wellness at MemorialCare Health System. It's time for Weekly Dose of Wellness. Here's Deborah Howell.

Deborah Howell (Host): And welcome to our show. This is your Weekly Dose of Wellness. I'm Deborah Howell, and today our guest is Dr. Ryland Melford III, a specialist certified in cardiovascular disease by the American Board of Internal Medicine. Dr. Melford comes to us today from Saddleback Memorial Medical Center in Laguna Hills. Welcome, Dr. Melford.

Ryland Melford, MD: Well, thank you. Good morning.

Deborah Howell (Host): Beautiful Laguna Hills, oh my, oh my.

Ryland Melford, MD: That's certainly true. We like to say it's another day in paradise here.

Deborah Howell (Host): Where is my golf club? All right, today we're gonna try to find out a lot more about statins, their uses, benefits, and side effects. We'll also try to debunk some of the myths surrounding this well-known treatment for high cholesterol. So first of all, doctor, what are statins?

Ryland Melford, MD: So statins, Deborah, are medications that are prescribed often by cardiologists or internal medicine physicians with the goal of lowering cholesterol. Now the statin actually acts on a specific enzyme in the liver, so I think it's important for patients to know that statins really do not impact the cholesterol that's in their diet that they ingest. It really, in fact, impacts instead the production of hepatic, or what we call liver-associated cholesterol.

Deborah Howell (Host): Interesting. Okay, so why are statins prescribed then?

Ryland Melford, MD: Right, and so what we found is that in prescribing statins, impacting this liver enzyme and thereby reducing the liver's production of cholesterol, we can impact the mediation of cholesterol moieties that increase risk of cardiovascular disease. And so we prescribe statins specifically to reduce those components of cholesterol metabolism that increase risk of cardiovascular disease, both in patients who have had cardiovascular events, heart attacks or strokes in the past, and those who are at high risk because of risk factors.

Deborah Howell (Host): Got it. Now who should be taking statins?

Ryland Melford, MD: Right, so typically a patient with a history of dyslipidemia, and then I can sort of simplify that to those with an elevated cholesterol, an LDL cholesterol, and that's important to know.

Deborah Howell (Host): The bad one.

Ryland Melford, MD: The bad cholesterol, right. And I always remember that, or remind patients that, remember L, so it's LDL, we want that one to be low, and the HDL we want to be high. So we look for patients who have a history of dyslipidemia with an increased risk of cardiovascular disease to be those that are primarily, that would primarily benefit from statin therapy.

Deborah Howell (Host): Okay, you see a lot of press coverage today and it's focused on the negative side of, you know, the effects of statins, so what do patients need to know about them?

Ryland Melford, MD: I think it's important to know that in general statins are very safe medications if prescribed appropriately and if monitored appropriately. Okay, and if you look at the clinical trials, the indications for stopping a statin in a patient is very low, okay, or the frequency rather, requiring cessation of statin therapy is very low. However, in clinical practice, in my clinical practice and those of my colleagues, it's not uncommon that a patient may experience, for instance, side effects related to muscle weakness or muscle pain. So it's important to note that if that circumstance becomes present, to notify your physician. But again, another concern has been the impact of statins on the liver or a potential for liver disease related to statins, and that is an important issue I think to debunk because the incidence of statin-associated liver disease is very rare. Okay, and it's very uncommon that a statin needs to be discontinued because of an increase in liver enzyme ratio or concentration. And then lastly I would say, and what we've seen more recently I think in the media, are the issues related to statins and memory loss or cognitive dysfunction. And there's really no strong data to support that, I have to say. I actually reviewed this again last night. But what we have found is that there is some anecdotal evidence that some of the statins, and those primarily that have been associated are lovastatin, fluvastatin, simvastatin and atorvastatin, could potentially be associated with memory loss, and so if a person, a patient rather, notes memory loss after statin is initiated, then they should contact their physician for evaluation. And then there are other statins too, in particular rosuvastatin and pravastatin, that could be considered in the high-risk individual and they haven't been associated with the memory deficit or cognitive dysfunction sort of complaints.

Deborah Howell (Host): Everybody's different, so everybody's gonna have a different reaction.

Ryland Melford, MD: Exactly.

Deborah Howell (Host): Are there any safety issues that patients need to be aware of when taking statins?

Ryland Melford, MD: Well, again, you know, I would say that the primary issues that we are interested in and we find clinically significant are those related to the liver. And again, what we do typically is we don't monitor liver enzymes in patients on statins, but we may check a baseline liver function test to begin after therapy is initiated. And again, I would caution patients if they notice any memory loss, or they seem to note or their family notes a change in their cognitive function, that certainly is something to alert your physician about. Any muscle pain or weakness, fatigue, those sort of symptoms should be reported to their physician. But again, I would stress that the requirement to decrease or to cease statin therapy related to adverse effects is a rare phenomenon despite what we may read in the media.

Deborah Howell (Host): Good to know. Now let's get into the good stuff, what are some of the benefits of statins?

Ryland Melford, MD: Right, right, so the benefits of statins again revolve primarily around their cholesterol-reducing capacity, but also around an additional benefit that one receives at the level of the vessel itself, so let's start with the cholesterol metabolism. Generally statins will reduce the bad cholesterol by 30 to 60%.

Deborah Howell (Host): Wow.

Ryland Melford, MD: Exactly, which is a dramatic reduction from our perspective. They will also help reduce the patient's triglycerides typically by about 20 to 40%. And generally as a class they will help to increase the HDL or the good cholesterol, again H we want it to be high, by about 5%. But I should also mention that that intravascular benefit results in essentially some blood thinning. The statin really, I guess the best way to say it in layman's terms is that the statin is able to promote health from an intravascular perspective which helps reduce the risk of heart attack and cardiovascular events by up to 30%. Which is a dramatic reduction.

Deborah Howell (Host): Definitely anytime you can get your cholesterol down to 30%, I mean down by 30%, is a good day.

Ryland Melford, MD: Absolutely.

Deborah Howell (Host): And even beyond that, how are statins useful beyond lowering cholesterol levels?

Ryland Melford, MD: Right, and again, so one interesting element in the history of statins is as they've been presented to the world is that we see a reasonable, no I'll say this, we see an essentially equivalent reduction in the risk of cardiovascular events in patients who have normal cholesterol compared to those who have elevated cholesterol. So again that points out the significance of the intravascular impact of statin therapy that is separate from the cholesterol-lowering capacity. Okay, and so that I think is really the significant benefit that we as cardiologists see because associated with that has been a significant reduction in the risk of cardiovascular disease and death in patients.

Deborah Howell (Host): Are some statins better than others?

Ryland Melford, MD: Right, so that's a good question and I would say I wouldn't say that there are statins that are quote, better per se. So in other words there is no statin that independently demonstrates greater efficacy or reduction in events. There are more potent statins, for instance rosuvastatin and atorvastatin are the two most potent statins in this class of medications and they will reduce the LDL by, you know, they're the ones who sort of sit in that 60% range of reduction at higher doses. And so it really is individualized, so I wouldn't say better, I would say that prescription of a statin should be on a more individualized basis depending on the patient's needs and risk.

Deborah Howell (Host): Got it. And is there a different level of statin for women versus men or maybe low body weight people versus higher body weight people?

Ryland Melford, MD: That's a good question and generally in general no. Now what has been seen however interestingly is that in the Asian population they tend to be more sensitive to lower doses of statins and so if you read the insert for rosuvastatin it actually recommends starting lower doses in Asian populations because of an expected dramatic effect or potential increased impact at the lower dose. And therefore hopefully fewer side effects associated with that initiation of therapy.

Deborah Howell (Host): That is very interesting.

Ryland Melford, MD: Right.

Deborah Howell (Host): I have one last question for you. Are statins the only way to manage cardiovascular risk?

Ryland Melford, MD: Oh that's an excellent question. And my answer to that is as a preventative cardiologist is absolutely not. In fact, you know, statins are only one component of a myriad of opportunities to modify risk. You know, from a pharmacological perspective obviously enteric-coated aspirin at a very low dose, 81 milligrams daily, can decrease cardiovascular risk in the appropriate population, again the higher risk population, by about 13%.

Deborah Howell (Host): Can I stop you there for one question? You said something about the coating I think which is important, maybe you can get into that just a little bit. The coating of the aspirin.

Ryland Melford, MD: Oh right, right, so enteric-coated aspirin is essentially aspirin that is coated to prevent its impact on the lining of the stomach, okay. So you know aspirin when not coated can have an impact on the lining of the stomach and theoretically increase risk of bleeding. So when it's enteric-coated that means that it's an aspirin that has a coating that prevents the impact of the actual acid and aspirin on the stomach lining, and so therefore shouldn't increase risk of bleeding, and it's something that we use in patients unless we're in an acute coronary syndrome where we need rapid absorption of aspirin.

Deborah Howell (Host): That is wonderful, wonderful tip for people, thank you for answering. And then back to the statins being the only way to manage cardiovascular risk.

Ryland Melford, MD: Right, and I would certainly use this opportunity or this last minute or two to stress the importance of the patient's involvement in management of cardiovascular risk. Diet and exercise are critical components and really can't be substituted for by any other therapy. But beyond that, excellent control of blood pressure, obviously good management of diabetes with a hemoglobin A1C goal of less than 7%, you know, these are the other elements that we look to, cessation of smoking and those sorts of things, okay. And so really to remove any element I think is, you know, challenging the best opportunity to care for patients because all of this, the entire constellation of what I've discussed is important in modifying risk in this very problematic disease.

Deborah Howell (Host): Just excellent information, thank you so much Dr. Melford for coming on the show today.

Ryland Melford, MD: Oh, it's my pleasure and thank you very much, I've enjoyed the time.

Deborah Howell (Host): We really appreciate it. And to learn more or to listen to a podcast of this show please visit memorialcare.org. I'm Deborah Howell, join us again next time as we explore another Weekly Dose of Wellness, and have yourself a fantastic day!