A Cardiologist Answers Your Questions About Statins

From muscle pain to memory worries, Dr. Rosen addresses follow-up questions about cholesterol drugs.

After Katie spoke with cardiologist Dr. Stacey Rosen about women’s heart health, the discussion covered a wide range of topics, from spotting a heart attack to making sense of cholesterol. Readers then continued the conversation online, sharing their own experiences and asking for more clarity about statins and how these medicines work.

We took some of the most important questions back to Dr. Rosen. Are statins a good option for older adults? What is known about muscle pain and memory concerns? Do women gain the same benefit as men? Here, she responds to those questions and explains why talking with your own clinician is essential when it comes to heart health.

Katie Couric Media: Some readers wanted to know whether lowering cholesterol is safe for older adults. What should they understand about statins as they get older?

Dr. Stacey Rosen: Cholesterol management in older adults is an important question. Older studies once suggested a link between low cholesterol and earlier death. But when those findings were reviewed more closely, it became clear that the lower cholesterol was often caused by serious illnesses such as cancer, heart failure, or liver failure, and those illnesses were what led to premature death. The low cholesterol itself was not the cause.

In fact, several major studies show that statins are safe and effective for the right older patients, at the right time, and at the right dose. One large analysis of 28 smaller trials found a 13% lower risk of heart disease with no increase in side effects. More recently, a study in the New England Journal of Medicine found that older adults taking statins lived longer and had a lower risk of heart disease and stroke, again without added side effects.

So I hope that helps put people at ease about statin use in older adults.

Readers also asked about coenzyme Q10, or CoQ10. How do statins affect it, and should people taking statins use a supplement?

Coenzyme Q10, also called ubiquinone or ubiquinol, is made through the same pathway that statins block. Because of that, statins can slightly lower natural CoQ10 levels. In the past, some people worried that this might lead to more muscle aches in statin users.

But further study showed that the reduction is very small and does not appear to be connected to muscle pain in people taking statins. Over many years, research has repeatedly found no link between CoQ10 levels and muscle aches. For that reason, CoQ10 supplements are not recommended for people on statins. The evidence supports the safety of statin treatment.

Muscle aches were another common concern. How often do they happen, and what can someone do if they experience them while taking a statin?

Statin-associated muscle symptoms, often called SAMS, are a frequent concern. After decades of research, clinical studies suggest that only about 1% or 2% of patients have mild muscle aches while taking statins. In everyday practice, though, these complaints may come up more often, so the issue remains important.

We know that more serious muscle problems, known as myopathy, occur in about 1 in 1,000 statin users. An even more serious condition, rhabdomyolysis, is seen in about 1 in 10,000 patients or even fewer. So while these drugs are generally very safe, a small number of people do experience muscle symptoms.

Sometimes simply expecting side effects can make them seem more likely. The good news is that there are many ways to adjust treatment if someone is having trouble with a statin. Some people take a pill only once or twice a week under a doctor’s supervision instead of every day. Other cholesterol-lowering medicines can reduce heart attack and stroke risk without causing muscle symptoms.

This is a good example of why treatment should be tailored to the patient and why it helps to work with a clinician to get the best cholesterol control with the fewest side effects.

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What is known about statins and the risk of memory loss or dementia?

Over the years, I have often been asked whether statins raise the risk of cognitive problems or dementia. It is one of the most persistent and concerning questions, but it has also been studied carefully, and there is a reason this concern began in the first place.

In 2012, the FDA added a warning that forgetfulness could occur in people taking statins, while also noting that it was very rare and reversible. Still, the idea that statins might cause memory loss, dementia, or other cognitive changes has lingered, prompting extensive research.

The reassuring news is that large trials in the United States and elsewhere have consistently found no increase in dementia, cognitive changes, or memory loss in people taking statins or even newer cholesterol-lowering drugs such as PCSK9 inhibitors.

It is also important to remember that if cholesterol is not lowered, plaque can build up not only in the heart’s arteries but also in the arteries of the brain. That plaque can contribute to dementia, vascular problems, and stroke.

When Katie mentioned a cholesterol number over 140, which number was she referring to? Can you explain the different numbers on a cholesterol panel?

When Katie and I were speaking, she was referring to an LDL above 140, and that is where my concern comes in. For almost everyone, that number is too high and would call for treatment.

It helps to understand what appears on a cholesterol, or lipid, panel. The test typically includes total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. The test may be done fasting or non-fasting; for many people either approach is fine, though fasting is sometimes preferred.

LDL is the so-called bad cholesterol, or low-density lipoprotein. It carries cholesterol from the liver to the rest of the body. When LDL is high, deposits can form plaque. As plaque builds in the arteries, the risk rises for heart attack, heart failure, stroke, and kidney disease.

For most people, the goal is an LDL below 100. If someone has already had an event or is at higher risk, the target may be below 70. For certain very high-risk patients who have had a heart attack or stroke, the goal may be as low as 55.

HDL, on the other hand, is the “good” cholesterol, and we want it to be higher. It acts like a cleanup system, collecting extra cholesterol from the bloodstream and returning it to the liver for disposal. Ideally, men should have an HDL above 40, and women should have one above 50.

Triglycerides are another type of fat in the blood, and they are the most closely tied to food intake. A large meal before lab work can make triglycerides appear elevated.

You may also have heard about lipoprotein(a) and apolipoprotein B. Those are additional tests that may be ordered or recommended, but the most important part is having a conversation with your clinician that is tailored to your needs.

Some readers wondered whether statins help women as much as men. What does the evidence show?

This is a very good question. In women’s health, a major issue has been that women were not always included in enough research. That has created a myth that women may not benefit as much from cholesterol-lowering medicines. The short answer is that statins work for both men and women and can significantly extend life by lowering the risk of heart attack and stroke.

Some important cholesterol studies did not include women at all. As a result, much of the early data came from men, and later research with only small numbers of women made it difficult to see the full effect. In that sense, the confusion came partly from the history of excluding women from clinical trials.

Since then, researchers have worked hard to include more women in cholesterol studies. Fortunately, decades of data now show that the small risk of side effects is the same in women and men.

Thank you for these important questions. And remember, the best approach is to discuss your own situation with your clinician so you can protect your heart health and address any concerns about risk factors or side effects.