Why Are Statins Different From Other Cholesterol Drugs?

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Question: Why Are Statins Different From Other Cholesterol Drugs?

My doctor says I should be treated for my high cholesterol, and wants me to begin taking medication. Even though there seem to be a lot of drugs on the market for cholesterol, she insists that I take a statin. Are the effects of statins really that much better than the other cholesterol drugs?

Answer: The main reason your doctor wants to lower your cholesterol is to reduce your risk of heart attacks and premature death from coronary artery disease (CAD).

And despite the fact that several classes of medications have been approved for lowering LDL cholesterol (LDL is the "bad" form of cholesterol), the only drugs that have been repeatedly shown to reduce the risk of heart attacks and premature death, in appropriately selected patients, are the statins. In fact, large studies have even suggested that some of the non-statin cholesterol medications can worsen outcomes.

Currently, it is thought that statins are better than other drugs at improving outcomes because they have several beneficial effects in addition to their cholesterol-lowering capabilities. These "extra" effects may help to prevent the rupture of atherosclerotic plaques in the coronary arteries, and may help to prevent acute coronary syndrome.

These "extra" effects of statins include:

  • An anti-inflammatory effect.
  • An anti-clotting effect.
  • A direct plaque-stabilizing effect.
  • A reduction in C-reactive protein levels (CRP)
  • An improvement in vascular function.
  • A reduction in dangerous cardiac arrhythmias.
  • Some regression (shrinking) of atherosclerotic plaques themselves.

These "extra" effects of statins may be even more important than cholesterol reduction in improving outcomes.

For instance, these non-cholesterol effects may be the reason that giving statins during acute coronary syndrome provides an immediate clinical benefit (a result that would not be anticipated if the only thing these drugs did was to reduce cholesterol). These non-cholesterol effects may also explain why statins can improve outcomes in certain high-risk patients whose cholesterol levels are not especially elevated to begin with.

Indeed, the unique benefits of statins have caused some experts to question the entire "cholesterol hypothesis" (the hypothesis that reducing cholesterol will reduce risk). These "heretics" believe it is not the reduction of LDL cholesterol that makes statins effective in improving outcomes, but the other effects of the statin drugs. So (they go on to suggest) maybe lowering cholesterol itself is not as important as we all think.

Either way, when your doctor recommends statin therapy as the best drug treatment for your elevated LDL cholesterol, she is simply demonstrating her knowledge of a substantial body of evidence suggesting that statins are uniquely beneficial.

Sources:

Davignon, J. Beneficial cardiovascular pleiotropic effects of statins. Circulation 2004; 109:III39.

Nissen, SE. High-dose statins in acute coronary syndromes. Not just lipid levels. JAMA 2004; 292:1365.

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