The push to expand prescriptions, despite doubts and good alternatives
Statins can reduce the risk of deaths from heart attack and stroke.
These drugs came to the fore because of their cholesterol-lowering powers.
Later, we discovered they also reduce inflammation and dangerous blood clotting — effects that significantly boost statins’ overall benefit.
Back in 2001, an expert panel at the National Heart, Lung, and Blood Institute released new guidelines that would result in 36 million adult Americans — nearly 20 percent — taking statins.
At first glance, this makes sense, since one-quarter of adult Americans suffer from heart disease, while nearly one-third have "high cholesterol" — meaning high overall levels and/or high LDL cholesterol levels.
But this sweeping recommendation seems to underplay the known — and unknown — side effects of statins, and the benefits that can be achieved by diet, supplements, and lifestyle.
Let’s examine the conflicting recommendations for prescription of statins for heart patients and non-patients with cardiovascular risk factors.
Then let’s review some of the natural ways to reduce cardiovascular risk, or ameliorate the adverse side effects of statins.
The standoff over statins
Should statins should be the first resort for treating high cholesterol?
The evidence on that score is mixed, compared with the clearer evidence that statins benefit people with heart disease and those who’ve suffered a heart attack or stroke.
Primary prevention is defined as reducing existing risk factors for cardiovascular disease, in the absence of diagnosed heart disease.
Two major health organizations provide differing prescription guidelines for statins.
Both groups’ guidelines cover people between the ages of 40 and 75 with no history of cardiovascular disease and triglyceride levels of 400 mg/dL or higher.
And both groups agree that anyone in this age group with an LDL cholesterol level of 190 mg/dL or higher should be on a statin.
But that’s where the guidelines of the two organizations diverge.
The American College of Cardiology/American Heart Association (ACC/AHA) offers these statin-prescribing criteria:
- LDL-cholesterol of 190 mg/dL or higher
- Diabetes and LDL-C of 70 mg/dL or higher
- Ten-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5% or greater and LDL-cholesterol of 70 mg/dL or higher.
The 2016 United States Preventive Services Task Force (USPSTF) offers these statin-prescribing criteria:
- LDL-C of 190 mg/dL or higher
- At least one cardiovascular risk factor (hypertension, diabetes, dyslipidemia, or smoking) and 10-year ASCVD risk of 10% or greater.
At first blush, these may not seem all that different, but they would result in markedly different numbers of Americans being prescribed statins.
Last year, researchers from Duke University and Canada’s McGill University calculated the difference in the number of statin prescriptions that would result from universal adoption of each organization’s guidelines (Pagidipati NJ, et al. 2017).
Under the 2016 USPSTF guidelines, an additional 15.8% of diagnosed heart patients would be prescribed statins, over and above the 21.5% of heart patients currently taking statins.
By comparison, adherence to the ACC/AHA guidelines would add an additional 24.3% of heart patients who'd be prescribed statins.
As the Duke-McGill team wrote, “… adherence to the 2016 USPSTF recommendations for statin therapy, compared with the 2013 ACC/AHA guidelines, could lead to a lower number of individuals recommended for primary prevention statin therapy, including many younger adults with high mean [average] long-term CVD risk.”
Of course, this leaves unanswered the question of whether statins are the only approach to lowering cholesterol levels and the risk for adverse cardiovascular events (e.g., heart attacks, strokes, and sudden cardiac death).
Before we discuss natural approaches to reducing risk, let’s look at the issue of age, and the risks of harm from statins.
What about people aged 75 or older?
Most studies of primary cardiovascular prevention only include people younger than 75 years.
Yet, according to the Centers for Disease Control and Prevention (CDC), nearly half of all adults aged 75 or older are taking statins.
However, as one expert recently told The New York Times, “For people over age 75 … there was not sufficient evidence to reach a conclusion. As with many clinical trials, the major statin studies mostly haven’t included patients at advanced ages.”
This means that some elders taking statins don’t need them and may suffer their side effects for no purpose, while others who aren’t taking statins who would benefit from the drugs.
One obvious concern about people in this age group is the fact that many seniors are on multiple medications, many of which interact with statins.
And up to 30% of people taking statins experience muscle aches and fatigue: side effects that would exert more serious effects among people already suffering from age-related loss of energy and muscle mass.
Because many statin questions remain unanswered when it comes to the senior population, the prevailing sentiment should be “first do no harm.”
Speaking of harm
Statins are linked to a variety of negative side effects, which range from minor to (rarely) dangerous.
However, because statins are relatively new drugs, it’s not clear whether their systemic effects produce damage that hasn’t yet become apparent.
Statins work in part by blocking the enzyme needed to produce cholesterol in the liver — but they also interrupt about 20 other essential biochemical pathways in the body.
Ironically, some of those biochemical pathways are crucial for maintaining cardiovascular health.
For example, statins reduce levels of coenzyme Q10 (CoQ10), which is essential to energy production in virtually every cell of your body, with the highest levels found in your heart, brain and liver.
This is a particularly concerning side effect, since coenzyme Q10 helps stop a pivotal step in artery clogging — oxidation of LDL-type cholesterol — and may help lower cholesterol levels.
And 50 to 75 percent of people diagnosed with cardiovascular disease — as well as many at high risk of heart attack, or who have diabetes or high blood pressure — suffer from low levels of CoQ10.
Cardiologists typically prescribe CoQ10 to people taking statins, but that’s not a universal practice, and it’s not clear that supplements eliminate the CoQ10 deficiency created by statin therapy. Aim for 100-200 mg of CoQ10 per day.
What about cancer?
Two evidence reviews published last year found no indications that statins raise the risk for breast cancer, although we lack evidence regarding long-term statin use and the risk for breast cancer.
On the plus side, there’s evidence that statins may help control aggressive breast cancers with poor outcomes (e.g., inflammatory and triple-negative breast cancers).
But on the minus side, a 2015 study found that statin use was associated with an increased risk for colorectal and pancreatic cancers.
And, as we noted, there’s a lot we don’t know about the systemic effects of statins, especially over the long term.
Going the natural route
If you have high cholesterol and are leery of statins, you do have a few options.
In addition to a healthy diet and regular exercise, there are three supplements you may to try: plant sterols, omega-3 fatty acids, and red yeast rice (a natural source of statins).
These waxy, naturally occurring substances occur throughout the plant world, with heavy concentrations in legumes and some seeds, including sunflower and sesame seeds.
They’re particularly heralded for their ability to reduce the inflammation in the arterial wall, which is a key driver of plaque buildup, and the risk of arterial plaque bursting and causing dangerous blood clots.
Plant sterols are so effective that the American Heart Association and the National Cholesterol Education Program recommend them for lowering elevated cholesterol levels. Aim for 2,000 mg of plant sterols daily.
Omega-3 fatty acids
Starting in the late 1960s, health authorities began urging Americans to replace cooking fats high in saturated fats — butter and lard — with vegetable oils.
All vegetable oils — except coconut oil — are high in unsaturated fats, which include polyunsaturated or monounsaturated fats.
The cheapest and most commonly used vegetable oils — corn oil, soy oil, safflower oil, sunflower oil, and cottonseed oil — are high in omega-6 polyunsaturated fats.
The only common vegetable oils with relatively low levels of omega-6 polyunsaturated fats and high levels of monounsaturated fat (oleic acid) are olive oil, canola oil, macadamia nut oil, and “medium oleic” or “high oleic” versions of safflower and sunflower oil. (Most sunflower oil sold in the U.S. is medium-or high-oleic.)
Although replacement of butter and lard with vegetable oils generally reduces cardiovascular health risks, there’s growing evidence that the difference is exaggerated, and that we’ve gone way overboard.
In fact, there’s good evidence that we’re consuming far too much omega-6-rich cooking oil — an excess that fosters a pro-inflammatory environment in blood vessels: see Vegetable Oils Debunked for Heart Disease and its links to related articles.
In contrast, omega-3 essential fatty acids from fish or supplements are powerful allies, because they improve cholesterol profiles, lower triglyceride levels, reduce inflammation, and prevent blood platelets from becoming sticky.
Those effects probably explain why omega-3s help prevent strokes and cardiovascular disease and reduce the risk of sudden cardiac death, second heart attacks, or congestive heart failure (see Heart Failure Findings Favor Omega-3s over Statin Drug).
And supplemental omega-3s (e.g., fish oil) appear to enhance and even rival the cardiovascular benefits of statins, and rival statins when it comes to reducing the risk of death from any cause: see Omega-3s Add to Statin Drugs' Cardio Benefits, Omega-3s Seen Rivaling Statins at Reducing Risk of Death, and their links to related reports.
Whether you’re taking a statin or not, aim for 1,000-2,000 mg of omega-3s a day, either from supplements or a combination of fatty fish and supplements: a 6-ounce serving of wild sockeye salmon provides almost 2,000 milligrams of omega-3s.
Red Yeast Rice
Red yeast rice extract contains naturally occurring lovastatin, the same active ingredient in the synthetic statin drug called Mevacor.
In fact, synthetic statin drugs were created after the discovery of that red yeast rice lowers cholesterol levels.
Synthetic statin drugs were created primarily so that pharmaceutical companies could patent those products, which you can’t do with a natural product like red yeast rice.
The amount of lovastatin in typical red yeast rice extracts is much lower than the amount in Mevacor.
Nonetheless, red yeast rice extract can cause the same side effects as synthetic statins, including abnormal liver test results and muscle weakness (myopathy). However, because the extract typically contains less lovastatin than its pharmaceutical counterpart, side effects are less common.
It’s important to note that different brands of red yeast rice contain different amounts of lovastatin, and the amounts can vary among batches from the same manufacturer.
Talk to your doctor before taking red yeast rice extract — he or she will probably want to monitor your liver function — and don’t take it along with prescription statins.
- Cleveland Clinic Health Library. Cholesterol Reduction: Red Yeast Rice and Plant Stanols. Accessed at https://my.clevelandclinic.org/health/articles/17417-cholesterol-reduction-red-yeast-rice-and-plant-stanols
- Fujimoto M, et al. Association between Statin Use and Cancer: Data Mining of a Spontaneous Reporting Database and a Claims Database. Int J Med Sci. 2015;12(3):223-33.
- Gu Q, et al. Prescription cholesterol-lowering medication use in adults aged 40 and over: United States, 2003-2012. NCHS Data Brief/CDC. Dec 2014;177.
- Islam MM, Yang HC, Nguyen PA, Poly TN, Huang CW, Kekade S, Khalfan AM, Debnath T, Li YJ, Abdul SS. Exploring association between statin use and breast cancer risk: an updated meta-analysis. Arch Gynecol Obstet. 2017 Dec;296(6):1043-1053. doi: 10.1007/s00404-017-4533-3. Epub 2017 Sep 22. Review.
- Kazi DS, Penko JM, Bibbins-Domingo K. Statins for Primary Prevention of Cardiovascular Disease: Review of Evidence and Recommendations for Clinical Practice. Med Clin North Am. 2017 Jul;101(4):689-699. doi: 10.1016/j.mcna.2017.03.001. Review.
- Kim SH, et al. Prospective randomized comparison between omega-3 fatty acid supplements plus simvastatin versus simvastatin alone in Korean patients with mixed dyslipidemia: lipoprotein profiles and heart rate variability. Eur J Clin Nutr. 2011 Jan;65(1):110-6.
- Kris-Etherton PM, et al. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation. 2002 Nov 19;106(21):2747-57.
- Leaf A. Historical overview of n-3 fatty acids and coronary heart disease. Am J Clin Nutr. 2008 Jun;87(6):1978S-80S.
- Lee BJ, et al. A significant correlation between the plasma levels of coenzyme Q10 and vitamin B-6 and a reduced risk of coronary artery disease. Nutr Res. 2012 Oct;32(10):751-6.
- Lewis SJ, et al. Effect of pravastatin on cardiovascular events in women after myocardial infarction: The Cholesterol and Recurrent Events (CARE) trial. J Am Coll Cardiol. 1998 Jul;32(1):140-6.
- Murakami R, Chen C, Lyu SY, Lin CE, Tzeng PC, Wang TF, Chang JC, Shieh YH, Chen IF, Huang SK, Lin HW. Lovastatin lowers the risk of breast cancer: a population-based study using logistic regression with a random effects model. Springerplus. 2016 Nov 8;5(1):1932. doi: 10.1186/s40064-016-3606-2. eCollection 2016.
- Pagidipati NJ, et al. Comparison of Recommended Eligibility for Primary Prevention Statin Therapy Based on the US Preventive Services Task Force Recommendations vs the ACC/AHA Guidelines. JAMA. 2017;317(15):1563-7.
- Petretta M, Costanzo P, Perrone-Filardi P, Chiariello M. Impact of gender in primary prevention of coronary heart disease with statin therapy: a meta-analysis. Int J Cardiol. 2010 Jan 7;138(1):25-31. doi: 10.1016/j.ijcard.2008.08.001. Epub 2008 Sep 14.
- Ras RT, et al. LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. Br J Nutr. 2014 Jul 28;112(2):214-9.
- Singh RB, et al. Effect of hydrosoluble coenzyme Q10 on blood pressures and insulin resistance in hypertensive patients with coronary artery disease. J Hum Hypertens. 1999;13:203-8.
- Span P. You’re Over 75, and You’re Healthy. Why Are You Taking a Statin? NYT. Jan 5 2018.
- Stone NJ, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S1-45.
- Studer M, et al. Effect of different antilipidemic agents and diets on mortality: a systematic review. Arch Intern Med. 2005 Apr 11;165(7):725-30. Review.
- Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD004816. doi: 10.1002/14651858.CD004816.pub5. Review.
- U.S. Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Recommendation Statement. Am Fam Physician. 2017 Jan 15;95(2). Accessed at https://www.aafp.org/afp/2017/0115/od1.html
- US Preventive Services Task Force, Bibbins-Domingo K, et al. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force Recommendations Statement. JAMA. 2016;316(19):1997-2007.
- Van Wyhe RD, Rahal OM, Woodward WA. Effect of statins on breast cancer recurrence and mortality: a review. Breast Cancer (Dove Med Press). 2017 Dec 1;9:559-565. doi: 10.2147/BCTT.S148080. eCollection 2017. Review.