I.V. Pershukov is a Doctor of Medical Sciences, Professor, and Head of the Department of Hospital Therapy with a course in Radiological Diagnostics and Oncology at Jalal-Abad State University.
- What is the role of statins in treatment? Is it possible to do without them?
- In the past, it was possible to manage without statins, but that is no longer the case. These medications not only lower the level of harmful cholesterol (LDL) but also significantly affect mortality and the incidence of cardiovascular diseases, especially among high-risk individuals. Statins, which belong to the class of HMG-CoA reductase inhibitors, are the main agents in the prevention of atherosclerosis and its complications.
The history of statin use dates back to the 1970s when Japanese professor Akira Yamamoto first used mevinolin to treat a girl with familial hypercholesterolemia.
Before 1994, the importance of statins was not so obvious, but then the results of the 4S study (Scandinavian Simvastatin Survival Study) involving 4,444 patients who had experienced a heart attack or suffered from angina appeared. This study first demonstrated that treatment with simvastatin at doses of 20–40 mg/day could significantly improve the prognosis for patients with dyslipidemia. The results showed that among patients taking simvastatin for 5.4 years, the number of heart attacks decreased by 34%, mortality from coronary heart disease by 42%, strokes by 28%, and overall mortality by 30%. In the control group receiving placebo, 202 people died over 5 years of observation.
This data became a decisive argument in favor of prescribing statins as medications that influence overall mortality and the frequency of cardiovascular events. Since then, statins have ceased to be viewed merely as a means to lower cholesterol levels.
Today, 32 years later, despite the availability of other medications that also help control cholesterol levels, such as ezetimibe and PCSK9 inhibitors (e.g., evolocumab and alirocumab), statins remain the primary and most effective means of preventing atherosclerosis and its complications.
- If a person's harmful cholesterol level is high, then its reduction is understandable. But why lower cholesterol levels when they are normal?
- Normal cholesterol levels are defined for healthy individuals; however, the laboratory cannot know the individual risks of each patient. Therefore, the doctor must assess these values and prescribe appropriate treatment.
Atheroma is an atherosclerotic plaque that impedes normal blood flow and causes symptoms of diseases such as coronary heart disease.
In people without risk factors for atherosclerosis, the likelihood of heart attack and stroke is low, but in patients with hypertension, this risk significantly increases. Therefore, leaving them at their previous levels of harmful cholesterol is dangerous, as it leads to an increase in cardiovascular diseases. The doctor should use scales to assess individual risks and determine target cholesterol values for each patient. These values may vary depending on health status: individuals with hypertension, angina, or those who have undergone coronary artery surgery have a higher risk. It is also worth noting that in Russia, target values for harmful cholesterol have been tightened twice in the last ten years, while globally, they have been tightened once.
- People take statins but do not reach target levels of harmful cholesterol. What should they do when they receive different answers to this question?
- Yes, this is a common problem. Studies show that among those who did not take statins, the frequency of atherosclerosis complications was the highest, while among those who took statins but did not reach target levels, the frequency of complications was lower. Only those who successfully reached and maintained the target cholesterol level had the lowest frequency of complications.
In recent years, expert opinions in the USA and Europe have diverged. The main differences between American (ACC/AHA 2013) and European (ESC/EAS 2011) guidelines are as follows:
- American guidelines:
- Suggest not monitoring lipid levels to assess treatment adherence.
- Recommend using only those doses of statins that have been studied in clinical trials, emphasizing high doses to achieve a 50% reduction in LDL.
- European guidelines:
- Consider the presence of four risk categories and their corresponding target LDL levels.
- Emphasize the importance of monitoring target cholesterol levels to assess treatment effectiveness and adherence.
In my experience working in a public clinic where patients come under the compulsory medical insurance policy, I have noticed that the prescription of statins and their monitoring leads to a significant reduction in harmful cholesterol in 70-80% of patients. They strive to track their indicators and actively participate in the treatment process.
- Is there a myth that statins are more harmful than beneficial, and can they cause cancer or diabetes?
- This is indeed a myth that exists among patients. Trust in doctors and their recommendations in the CIS countries is unfortunately low. In contrast to countries in Europe, the USA, Japan, and others, where trust in doctors is much higher.
A recent study published in the British Medical Journal covers the use of statins in 91 countries from 2015 to 2020.
Statistics on statin use by regions of the world from 2015 to 2020.
The highest level of statin use is observed in North America, followed by Europe, then Latin America, the Middle East, and North Africa. The lowest levels are recorded in East and South Asia, as well as in Sub-Saharan African countries.
Statin use by country from 2015 to 2020.
It is important to note the following:
- Statins do not have a negative impact on the risk of developing cancer with long-term use; some studies even show a reduction in this risk.
- Statins do not contribute to the development of diabetes with long-term use; meta-analyses do not confirm such a connection.
- Statins do not increase the risk of liver cirrhosis with long-term use.
It is important to note that the risk of serious complications associated with statin use is extremely low — rhabdomyolysis occurs in less than one in a million patients taking the specified doses of statins.
In my practice, there have been no cases of persistent elevation of liver enzymes that could not be resolved; rare elevations in AST and ALT easily resolved after discontinuation or dose reduction of statins. In one case, hepatitis was caused by the hepatitis B virus, and the patient successfully underwent treatment.
Thus, my recommendations regarding statins are unequivocal: they are necessary for patients at risk of atherosclerosis and its manifestations (coronary heart disease, myocardial infarction, stroke, etc.). Their proper use is the key to the health of society.
