The Role of Statins in Heart Health

Want to learn more about the heart protective effects of statins? Medicines in this class are recommended for many people including those with diabetes and with heart disease or heart disease risk factors. Learn more about the use of these medicines, including effects on lowering cholesterol levels, side effects, and the role of these medicines in supporting heart health and the treatment of heart disease.

It’s important for people to know that diabetes is a major risk factor for heart disease. According to the CDC, a person with diabetes is two times more likely to have heart disease or a stroke than someone without diabetes. Heart disease is often a “silent” condition – people may not show any symptoms until a heart attack or a stroke occurs. Individuals with type 2 diabetes (and some with type 1 diabetes) may also experience other risk factors for heart disease, such as hypertension (high blood pressure), elevated LDL-cholesterol (the “bad” cholesterol), low HDL-cholesterol (the “good” cholesterol) and obesity.

The American Heart Association and the American Diabetes Association have teamed up to create the Know Diabetes by Heart (KDBH) initiative, which helps people with diabetes learn the best ways to support their heart health. There are many steps you can take to take care of your heart and reduce the risk of heart disease when living with diabetes. One option for those with high LDL-cholesterol is a group of medicines known as “statins.” These medicines have been shown to lower LDL cholesterol levels, which helps protect the heart, and reduce the risk of heart-related disorders.

What are statins?

Statins work by slowing down the liver’s ability to produce low-density lipoprotein (LDL or “bad”) cholesterol by blocking the effects of an enzyme that makes cholesterol (An enzyme is a type of protein that helps speed up chemical reactions – in this case the production of cholesterol). This enzyme is found in your liver and is called HMG-CoA-Reductase. Because your liver is not making as much cholesterol as before, it has to pull cholesterol out of your blood stream in order to make substances, such as bile, that helps you digest food. In this way statins decrease the total amount of cholesterol in your blood stream.

In addition to lowering LDL cholesterol, statins can also lower triglyceride levels. Triglycerides are a type of fat found in our blood and high levels may cause or contribute to heart disease or damage to your pancreas (called pancreatitis). In order to treat high levels of triglycerides with a statin, a high dose is required and statins are not usually the first line of therapy for this condition. 

Statins can also raise the amount of high-density lipoprotein (HDL)-cholesterol levels. HDL – the “good” cholesterol in our bodies – is important for clearing fat from our arteries. It can be increased through routine exercise, quitting smoking, switching to a healthier diet, and weight loss. 

Along with cholesterol levels, there are several other modifiable risk factors for heart disease. If you have multiple risk factors for heart disease, ask your healthcare provider about ways that you can reduce your overall risk of developing heart disease. Other modifiable risk factors include:

• High blood pressure (or hypertension)

• Being overweight or obese

• Smoking cigarettes

• Excessive consumption of alcohol

• A Lack of physical activity

• Stress

• Nutritionally deficient diet (eating a high sugar, high fat, or high salt diet)

What are the recommendations for statin use?

Because of the increased risk, people with diabetes are very often prescribed a statin to help prevent heart disease and to lower their risk of experiencing a heart attack or stroke. Guidelines from the American Diabetes Association (ADA) and the American Heart Association (AHA) recommend statin therapy – in conjunction with lifestyle modifications – for the prevention of heart disease in most individuals with diabetes, regardless of cholesterol levels.

Statin doses or regimens are often described by their “intensity” level – low, medium, or high. The intensity of a statin is determined by an individual’s risk of heart disease or stroke, accounted for by factors such as age, history of heart disease or stroke, or other medical conditions). 

The current ADA guidelines include the following recommendations for statin use, according to intensity, depending on a person’s age (which is often a major risk for heart disease and stroke by itself):

• Younger than age 40 years: 

  • No statin for individuals without heart disease risk factors other than diabetes and with LDL cholesterol below 100 mg/dL.

  • Moderate intensity statin treatment is recommended for all individuals with diabetes and LDL cholesterol of 100 mg/dL or greater.

  • Moderate or high-intensity statin regimen for those with additional heart disease risk factors such as: high blood pressure, smoking, or excess weight or obesity.

  • High-intensity statin regimen for those with overt heart disease, such as those who have experienced a previous cardiovascular event (such as a stroke or heart attack) or those who have experienced acute coronary syndrome (this is a range of conditions associated with sudden, reduced blood flow to the heart).

• Age 40-75 years: 

  • Moderate-intensity statin regimen for all individuals with diabetes, even with no additional heart disease risk factors.

  • High-intensity statin regimen for individuals with either heart disease risk factors or those who have heart disease.

• Older than 75 years: 

  • Moderate intensity statin treatment is recommended for all older individuals with diabetes and LDL cholesterol of 100 mg/dL or greater.

  • Moderate-intensity statin regimen for individuals with heart disease risk factors.

  • High-intensity statin regimen for those who have heart disease.

What about side effects?

Statins are generally well tolerated, and larger clinical trials have suggested that they are very safe.

Some people who take statins may report muscle pain, aches, or weakness and may discontinue their medication because of it. The good news is that many controlled trials comparing people given statins or a placebo show that there is no difference in muscle pain symptoms between the statin and the placebo. However, if you are starting a new statin regimen or believe you are experiencing muscle pain that could be related to your medication use, do not hesitate to contact your healthcare professional. 

It is important to know that a severe form of muscle pain – called rhabdomyolysis – is a very rare complication from statins.

Statins should not be used by women who are pregnant or who may become pregnant.

Taking statins – what to know

Statins are a type of medication usually taken in pill or tablet form by mouth once a day for the long-term. Their effects on lowering cholesterol are usually observed within two to three months after starting treatment. Your healthcare provider may schedule blood work periodically to evaluate the effects of these medicines on your cholesterol levels and liver function. 

Statins may interact with other medicines and cause side effects. Talk with your healthcare provider about any other medicines you’re taking before you start taking a statin.

Some commonly prescribed statins include:

• Lipitor (atorvastatin)

• Lescol (fluvastatin)

• Mevacor, Altoprev (lovastatin)

• Pravachol (pravastatin)

• Livalo (pitavastatin)

• Zocor (simvastatin)

• Crestor (rosuvastatin)

Getting the most from your statins

If you’ve been prescribed a statin, there are some important tips to be aware of to get the most benefit out of the medication. Statins work best when taken every day at the same time each day. You may be told to take your statin medication at bedtime or in the evening. This is because our liver is most active in making cholesterol at night. While many statins work best in the evening, four statins – Lipitor (atorvastatin), Crestor (rosuvastatin), Pravachol (pravastatin), and Livalo (pitavastatin) – can be taken at any time of day.

If you forget to take a dose of your medicine, and don’t remember until your next dose, it is not encouraged for you to take an extra dose to make up for the one you’ve missed. Talk to your doctor about what you should do if you forget to take your statin medication when you are supposed to.

Reach out to your healthcare provider if you believe you are experiencing side effects. While statins might cause muscle pains or cramps, you should not stop taking them without contacting your healthcare professional. Your healthcare professional may suggest trying a lower dose or a different medication from this class.

Avoid grapefruit juice if you are taking Zocor (simvastatin) or Mevacor/Altoprev (lovastatin) and limit your grapefruit juice intake to less than two small glasses per day if you have been prescribed Lipitor (atorvastatin). Grapefruit juice blocks the liver’s removal of these statins from the body, and thus drastically increases their levels in the blood.

While statins are an effective class of medicines for lowering cholesterol and heart disease risk, they aren’t a substitute for a healthy diet and lifestyle. Work with your healthcare team to determine what you can do to eat healthily, be active, limit alcohol, and stop smoking if you smoke. And be sure to keep track of metrics that affect your heart health such as your kidney function, BMI, or blood pressure.

What to ask your healthcare professional 

If you want to learn more about statins or determine if the statins are right for you, a great place to start is by asking your healthcare professional. Some questions to ask your healthcare professional might be:

• What are my individual heart disease risk factors? 

• What is my BMI, waist circumference, blood pressure, and A1C?

• What is my cholesterol level? Should I try to lower my cholesterol or heart disease risk by changing my diet? 

• What do my eGFR and UACR tests mean and are my kidneys functioning properly?

• Should I include more physical activity? 

• Is starting a statin a good idea at this time?

One of the most important things you can do to protect yourself from heart disease and stroke is to know your risk factors and track critical health metrics including your BMI & waist circumference, blood pressure, A1C, cholesterol, and kidney function. Ask your doctor where you fall within each of these metrics how you can improve them.

For individuals without diabetes, there is evidence that statins may increase blood sugar levels and your risk of developing diabetes – the risk for increased blood sugar levels is included as a warning from the FDA on the drug label for statins. Have a conversation with your healthcare team to weigh the risks of this medication class with your potential individual benefits. 

If you are starting a statin, be sure to ask about any specific drug or diet interactions you may need to watch out for.

Bottom Line

You can reduce your risk of heart disease while living with diabetes through your lifestyle and medication use. You can work together with your healthcare team to develop a personalized plan to determine the best ways for reducing your risk of heart disease. Statins can be very useful for people living with diabetes who have high cholesterol, heart disease, or are at risk of heart disease, according to the latest evidence and treatment recommendations. If you want to learn more about how you can make the most of your diabetes medication plan, be sure to visit Know Diabetes by Heart or read some of our other articles, including: 

• What Are GLP-1 Agonists and How Can They Help Your Heart?

• What Are SGLT-2 Inhibitors and How Can They Help Your Heart?

About Mary

Mary Barna Bridgeman, PharmD, BCPS, BCGP is a Clinical Professor at the Ernest Mario School of Pharmacy at Rutgers University. She practices as an Internal Medicine Clinical Pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.