When To Take A Statin?

A cholesterol pill helped prevent heart problems in people with no major risks, a study found. Almost 18,000 people with normal cholesterol got either a cholesterol-lowering pill called Crestor, or a dummy pill. Those on Crestor had about half the number of heart problems. But even people taking the fake pill had a low risk of heart problems. The study was reported November 9 at an American Heart Association conference.

What Is the Doctor's Reaction?

The headlines don't reflect the real importance of this study, called the JUPITER study. Sure, the results will likely prompt more use of statins for prevention of heart attacks and strokes. But more importantly, it emphasizes how much more we can do keep our arteries healthy, even without drugs.

Many people have cardiovascular disease, despite having relatively normal LDL and HDL cholesterol levels. Low-grade inflammation appears to be one of the reasons why this happens. One measure of low grade inflammation is a test called a high-sensitivity C-reactive protein (CRP) test.

The goal of the study was to determine whether people with LDL cholesterol level of less than 130 (relatively low risk) and elevated high-sensitivity CRP value would have fewer heart attacks and strokes if they took a statin drug. The statin used in this study was rosuvastatin (Crestor). The money to perform the study was given by AstraZeneca, the company that makes Crestor.

The study randomized people with similar levels of "normal" LDL cholesterol and elevated levels of CRP. One-group was given rosuvastatin, and the other group was given a placebo. The subjects in the study were not told whether they were taking the statin or the sugar pill.

The people who took the rosuvastatin cut their level of LDL cholesterol by 50 percent, from an average of 108 to 54. The ones who took the placebo stayed at 108. Also those who took rosuvastatin had a 30 percent decrease in CRP level. No change for the placebo group.

It might seem a bit odd that my enthusiasm for this study is less about statins and more about lifestyle choices. Here's why. The study did not evaluate how evaluate how much your LDL cholesterol and CRP would decrease with a healthier diet, more exercise and quitting smoking compared to just taking the statin.

What Changes Can I Make Now?

Personally, I don't see this immediately changing what I advise patients now. I am already a big fan of statins. They are in my mind one of the most important drug discoveries of the last few decades.

But that doesn't mean that everyone should be taking them if their only risk factor is an LDL cholesterol level that is greater than 100. All the other risk factors need to be taken into consideration. For example, if a person has a family history of heart attacks and strokes, then taking a statin for cholesterol of 100 or higher might be reasonable. I would offer this, but not insist on it, even without a CRP level.

But for someone with absolutely no other risk factors, a history of longevity in the family and an LDL level between 100 and 129, I don't think this automatically means taking a statin. I would offer a CRP test. Not that I would immediately write a prescription for a statin if it the CRP test was high.

With a high CRP and LDL of less than 130, I would encourage a diet with even more vegetables, fruits, whole grains and less saturated fats. If possible, aim for about 45 minutes per day of moderate exercise and additional bits of physical activity throughout the day. If the LDL and CRP were still high after 3 to 6 months of real lifestyle change, it would be reasonable to consider a statin.

What Can I Expect Looking to the Future?

I do expect that the guidelines for prevention of heart attacks and strokes will be modified based upon this study and others that will follow. But I suspect that the changes will be relatively minor. Likely the changes will suggest offering CRP testing and earlier use of statins after discussion of the pros and cons with each patient.