Heart disease, cholesterol and statins: Your questions answered

As a cardiologist, many of the questions I’m asked on a daily basis concern statin drugs. It is my opinion that the medical profession gives statins too much power, but patients and the general public give statins too much pain. Here are my answers to five of the most common questions I’m asked about cholesterol and statins.

1) If my cholesterol is high and I don’t lower it, am I destined to have a heart attack?

This is a common misconception. The reality is that in certain cases sub-fractions of cholesterol may spill into your arteries but in other cases this is not true.

A very common misconception is that LDL cholesterol is bad and HDL cholesterol is good. This is actually far too simplistic, with the reality being both LDL and HDL are divided into small and large sub-fractions.

In general (and here’s where size is important), the larger your LDL and HDL, the healthier your cholesterol profile. Although the sub-fractions can be measured, they are not covered by Medicare and this will cost you about $250.

The most effective way to determine whether your cholesterol profile is contributing to fat build-up in the walls of your arteries (the precursor to a heart attack) is to have a coronary calcium score determined by CT scanning technology. There is another test using the same technology, known as intravenous CT coronary angiography, which has been shown in a recent study to be inferior to coronary calcium scoring but also more expensive, typically uses more radiation and also requires an intravenous injection of dye that potentially may damage your kidneys or possibly even induce anaphylaxis.

In my opinion, all males at 50 at all females at 60 should have a coronary calcium score as part of their risk factor assessment for heart disease. If you have existing heart disease such as a prior history of heart attack, coronary stent or coronary bypass grafting, you should be on a statin regardless, and a coronary calcium score is of no value.

2) Are all statins the same?

No. Basically, statin drugs are divided into water soluble and fat soluble. Although there are no clinical papers to support this comment, it is my clinical experience that the water-soluble drugs are somewhat safer than the fat-soluble drugs and therefore if I believe someone requires a statin then I will prescribe water-soluble statins, such as rosuvastatin and pravastatin.

In my opinion, if your coronary calcium score is greater than 100 and you are between the ages of 50 and 70 or you have a prior history of heart disease, then you should be on a statin, as long as it does not cause you serious side effects.

3) If I eat a good diet, why do I need a statin?

You may be surprised to hear that diet has a minimal effect on cholesterol, contributing only up to 30 per cent of your cholesterol levels. Meanwhile, 70 per cent of your cholesterol is related to genetics and metabolism.

Just because you have a genetic elevation in cholesterol, doesn’t automatically mean that this cholesterol is spilling into your arteries. That’s the reason to have the coronary calcium score.

It is often a knee-jerk reaction by members of the medical profession to see that your cholesterol is elevated and immediately put you on a statin. This should not be done without determining your true risk with the coronary calcium score.

4) If I commence a statin, am I on these for life?

Yes, if you have proven heart disease or a high coronary calcium score and the statin is not causing you a side effect, this will give you extra insurance against developing progressive severe heart disease. However, there are new advances in all aspects of medicine and over the next few years there will be emerging cholesterol-lowering therapies coming onto the market that in some cases may replace statin therapy.

5) Do you statins cause dementia?

No. Statins may induce a completely reversible memory loss in a small proportion of patients (more commonly seen with the fat-soluble statins: atorvastatin and simvastatin).

Often people who have significant vascular disease who have survived their younger years start to have problems with cognitive impairment and early dementia. They are also typically on statins, and rather than blame the underlying condition, they falsely believe that it’s the statin that is causing their memory problems. There is a very simple solution, which is to stop the statin temporarily for a month or two to determine whether the memory improves. Typically it doesn’t and the statin should be recommenced as part of the long-term management because of the underlying vascular disease.

IMPORTANT LEGAL INFO This article is of a general nature and FYI only, because it doesn’t take into account your personal health requirements or existing medical conditions. That means it’s not personalised health advice and shouldn’t be relied upon as if it is. Before making a health-related decision, you should work out if the info is appropriate for your situation and get professional medical advice.