Igor Vladimirovich Pershukov is a professor and doctor of medical sciences, heading the Department of Hospital Therapy with a course in Radiological Diagnostics and Oncology at Jalal-Abad State University.
- What is the necessity of statins? Can we do without them?
- Previously, this may have been relevant, but under modern conditions, statins have become indispensable. These medications not only lower the level of bad cholesterol (low-density lipoproteins) but also significantly reduce mortality and the risk of heart attacks and strokes—especially in patients with high and very high risk. HMG-CoA reductase inhibitors, which include statins, play a key role in the primary and secondary prevention of atherosclerosis and its complications.
The origins of statin use date back to the 1970s when Japanese professor Akira Yamamoto first used mevinolin to treat a girl with familial hypercholesterolemia.
However, until 1994, the necessity of statins was not so obvious. There were several drugs in this group that lowered harmful cholesterol levels. In 1994, the results of the 4S study (Scandinavian Simvastatin Survival Study), conducted on 4,444 patients who had suffered a heart attack or had angina, changed the perception of statins. The placebo-controlled clinical trial showed that simvastatin therapy at doses of 20–40 mg per day significantly improves prognosis in severely ill patients with dyslipidemia. According to 4S, patients taking simvastatin for 5.4 years experienced a 34% reduction in heart attacks, a 42% reduction in mortality from ischemic heart disease, a 28% reduction in strokes, and a 30% reduction in overall mortality. Over 5 years of observation, among those taking placebo, 202(!) people died from recurrent complications of atherosclerosis.
This data became a decisive argument in favor of statin therapy, confirming their impact on overall mortality as well as the frequency of heart attacks and strokes. Since 1994, the use of statins has ceased to be perceived solely as a means of lowering cholesterol levels.
Today, 32 years later, although other medications have appeared in doctors' arsenals, such as ezetimibe (a cholesterol absorption inhibitor in the intestine) and PCSK9 inhibitors (e.g., evolocumab and alirocumab), statins remain the most common and effective therapy for the prevention and treatment of atherosclerosis and its complications.
- If a person has high cholesterol levels, it is clear why it needs to be lowered. But why lower the level of harmful cholesterol if it is normal?
- Normal indicators were established for practically healthy individuals. Laboratories cannot account for the individual risks of each patient; their task is to correctly determine the level of cholesterol and its fractions. The assessment is made by doctors.
Atheroma is an atherosclerotic plaque that obstructs normal blood flow and causes symptoms of diseases such as ischemic heart disease.
In a healthy person without risk factors for atherosclerosis, the likelihood of a heart attack or stroke is minimal. However, in a patient with hypertension, these risks significantly increase. Therefore, leaving the level of harmful cholesterol at the same level in such patients is dangerous, as it may lead to an increase in the number of heart attacks and strokes. In this regard, scales have been developed to allow doctors to determine target values for harmful cholesterol based on the individual risk of the patient. These risks vary: they are one level for patients with hypertension, higher for those with angina, and even higher for those who have undergone coronary bypass surgery or a heart attack. It is important to note that in Russia, over the past ten years, target values for harmful cholesterol have been lowered twice, while in the world, this has occurred only once.
- But what should be done if people take statins but do not reach target levels of harmful cholesterol? What should they do if they encounter differing opinions in practice?
- Yes, this is a common problem worldwide.
Studies show that people who have not taken statins have the highest frequency of atherosclerosis complications, while those who used statins but did not reach the target level have a lower frequency, and only those who managed to maintain the target level have the lowest frequency of complications.
As a result, in recent years, expert opinions in Europe and the USA have diverged. The key differences between American and European recommendations are as follows:
- American ACC/AHA 2013 recommendations:
- The "fire and forget" approach; monitoring lipid levels is not required to assess effectiveness and patient adherence.
- Only doses of statins that have been studied in randomized trials are recommended; emphasis on high doses of statins to reduce LDL levels by 50% (atorvastatin 40-80 mg and rosuvastatin 20-40 mg).
- European ESC/EAS 2011 recommendations (The European Atherosclerosis Society):
- Four risk categories and their corresponding target LDL levels must be considered.
- It is important to evaluate target levels of LDL cholesterol and other lipid parameters to monitor effectiveness and adherence.
From my personal experience as a doctor who has worked for 10 years in a state clinic in Russia, where patients come under the compulsory health insurance policy and usually have lower adherence than those who use paid medical services, it is evident that among the 24,000 patients who have passed through my practice (of which 85-88% needed statin therapy), the prescription of statins and their monitoring led to a significant reduction in harmful cholesterol and achievement of target levels in 70-80% of patients. This indicates a high level of adherence among my patients. As a practicing physician and researcher with over 15 years of experience, I have evaluated various doses and combinations of statins. I rarely used maximum doses, only in cases where lower doses were ineffective. All patients knew their target levels and sought to maintain observation tables, which brought them satisfaction.
- Is there a myth that statins are more harmful than beneficial? That they can cause cancer, diabetes, and liver problems?
- The question contains the key word "myth." This is a misconception prevalent among patients. Unfortunately, trust in doctors in the countries of the former USSR is far from ideal, while in Europe, the USA, Canada, Japan, Australia, and Israel, it is significantly higher.
A recent study published in the British Medical Journal (BMJ Open 2022;12:e061350. doi:10.1136/bmjopen-2022-061350) covered 91 countries and revealed how statins are used in different regions.
The frequency of statin use by regions of the world from 2015 to 2020
The highest level of statin use was recorded in North America, followed by European countries, then Latin America, the Middle East, and North Africa. The lowest figures are observed in East and South Asia, as well as in sub-Saharan Africa.
Statin use by countries from 2015 to 2020.
After presenting this statistics, I would like to note the following:
- Long-term use of statins does not cause cancer, and in some studies, a decrease in its incidence has even been noted.
- Statins do not provoke diabetes with prolonged use. Numerous studies and meta-analyses have found no such connection.
- Statins do not increase the risk of liver cirrhosis with prolonged use.
The frequency of serious complications from statin use is very low; rhabdomyolysis occurs in less than one in a million patients taking atorvastatin or rosuvastatin at recommended doses.
In my practice, there have been no cases of persistent elevation of liver enzymes that could not be resolved, and rare elevations of AST and ALT by 5 times or more returned to normal after lowering the dose of statins. The only case of hepatitis was caused by a co-infection with the hepatitis B virus.
Thus, my recommendations for the use of statins are clear: they are necessary for patients at risk of atherosclerosis and its manifestations (chronic ischemic heart disease, myocardial infarction, stroke, diseases of the arteries of the lower extremities, etc.). Proper and controlled use of statins is the key to the health of the nation.
