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Understanding Statin Therapy · UK HealthCast

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Amanda (Host): Welcome to UK HealthCast, a podcast presented by UK Healthcare.
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We're talking about statin therapy with Dr.
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Lucas Shelton, medical director of UK Healthcare Primary Care Frankfurt.
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I'm your host, Amanda Wilde.
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Dr.
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Shelton, welcome to the podcast.
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Thank you so much for being here
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Lucas Shelton, MD: Yeah.
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Thank you for having me.
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Um, I'm excited to share what I know about statins.
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Uh, it's a very relevant topic in, in medicine right now
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Amanda (Host): And very widely used.
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So first of all, what exactly are statins?
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Lucas Shelton, MD: statins are a medication, uh, that treat, cholesterol
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in, in terms of lowering certain types of cholesterol in our bodies.
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They, they act on the pathway of where cholesterol is, processed
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and synthesized in the liver.
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And the part of the pathway they act on kind of leads to a downstream effect
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of decreasing the amount of cholesterol that is most associated with, uh,
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things like heart attack and stroke
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Amanda (Host): When are statins indicated?
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Lucas Shelton, MD: to answer that question, we have to break patients
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up into two different, categories.
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Those two categories are called primary prevention and secondary prevention.
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Uh, so I think answering the question comes down to which
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bucket do I as a patient fit into if I have high cholesterol?
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I'll start with actually the secondary prevention category.
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Uh, so people in general will be in the secondary prevention category
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if you've had a cardiovascular event, uh, such as a heart attack
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or an ischemic stroke, or what is often referred to as a mini stroke.
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So those events, uh, define individuals as having what we call
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atherosclerotic cardiovascular events.
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Other conditions that can place patients into the secondary prevention category,
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really include arterial disease.
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And so arterial disease can be peripheral in the extremities
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of the arms or the legs.
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Arterial disease can be in the coronary arteries.
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Uh, those are the arteries that supply blood flow to the heart itself.
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And then the other kind of arterial disease that can happen is even in
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the abdomen and also up in the head and neck within the carotid artery.
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So
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arterial disease is cholesterol plaque buildup within the walls of arteries.
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So arterial disease and then those events I alluded to just a little bit
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ago, if patients have any of those conditions or that history of event,
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no matter what the cholesterol panel looks like for that patient, statins
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have proven benefit for those patients.
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So that's secondary prevention.
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Primary prevention includes patients who have never had a cardiovascular event
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like what I just mentioned, and they don't have any known arterial disease.
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And so that's more of a patient that I en-encounter very commonly
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in my primary care practice.
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That's a patient who comes in for annual labs, and I, I check so
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many, it's called a lipid panel.
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you know, lipid panels give me a readout on the different types of
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cholesterol within the bloodstream.
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And that's a patient who we sit down together, we are talking
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about how the cholesterol looks and the overall cardiovascular risk.
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And if you have enough risk, if you're in the primary prevention category,
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statins can be indicated as well.
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So those are the two main categories of people who can benefit from statins
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Amanda (Host): So in primary care, this is when you first start thinking this patient
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may need a statin if they have one of these health conditions or risk factors.
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What are the benefits of statins?
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How, and how do they work in the body?
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Lucas Shelton, MD: So the benefits of statins in the secondary prevention
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group of patients, they help prevent future events like future
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heart attacks and future strokes.
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They are proven to decrease the chances of those things happening in
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the future, which we obviously want to decrease the chances of those.
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They decrease the chance of death from, uh, cardiovascular events and disease.
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Those are two main categories of benefit that's proven within the
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secondary prevention group of patients.
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And then within the primary prevention, part of the reason it's named primary
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prevention is for patients who have enough risk, who have never had an event,
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there's evidence, good evidence, that shows that statins help decrease the
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chance of the first stroke, heart attack, or arterial disease, uh, development.
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So, um, it's all about preventing the first event if patients
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have never had one before.
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And statins are just working there in the liver, to decrease that
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type of cholesterol called the LDL that's most associated with these
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things like heart attack and stroke
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Amanda (Host): Are there any side effects to statins?
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Lucas Shelton, MD: Yes.
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Most common, uh, side effect with statins have to do with muscle.
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In clinical practice, up to about 10% of patients can experience
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what we call myalgias, uh, which is a muscle ache or a muscle pain.
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It has to do with the way that, uh, statins can also work within muscle
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tissue Randomized control trials, which are the highest quality type of
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study, have actually shown that most of the patients who experience muscle
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aches from statins, that is actually attributable to what's called a nocebo
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effect, which means that patients can go on to taking a statin almost with
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the expectation of having a side effect.
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And so it's not actually the effect of the medicine itself,
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it's, um, more of a certain type of placebo that we call nocebo.
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but I don't mean to say at all that there's not true muscle
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issues that go on sometimes.
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There, there are, and I, you know, I tell my patients, "Hey, if you have
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muscle aches, muscle cramps with this medicine, please let me know.
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We can always try a different statin or an alternate medicine."
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Uh, so that, that's one of the most common side effects.
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There are some more rare side effects.
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Uh, one of the things that we'll be seeing in literature, uh, is a very small
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chance of actually the development of diabetes, uh, with statin medications.
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0.2%
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per year is the rate of developing diabetes with, uh, statin medication.
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But the way I always kinda discuss about that with my patients is,
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let's say we have a patient who has pre-diabetes, and they are almost
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at the point of having diabetes.
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And let's say they're, they're not on a statin, and their cholesterol is, is to
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the point where I think that they would have benefit from being on a statin.
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I would never hold off recommending a statin for fear of pushing that
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patient into diabetes, because the overall cardiovascular benefits
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of statin therapy, if I feel like it's warranted, far outweighs that
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small chance of developing diabetes.
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And I'll kinda finish that thought with this.
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Diabetes in and of itself is such a risk factor for cardiovascular
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disease that, most patients over 40 with diabetes need a statin anyway
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just by the fact of having diabetes.
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So, answer to that question, there's a very, very rare, liver toxicity
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that can happen from statins.
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It is so rare that, About 13 or 14 years ago, the recommendation
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to trend liver enzymes while being on statin actually went away.
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There's no good evidence to do that now, uh, but very, very rare.
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I believe the exact percentage is 0.001%
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of the severe liver toxicity Now there are certain liver conditions where we want to
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be cognizant as prescribers of, "Hey, do we need to maybe hold off on the statin?"
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But that is our responsibility, uh, as prescribers to have
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that discussion with patients
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Amanda (Host): Well, thank you for putting the side effects in perspective.
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When we talk about statin therapy, are statins something you take
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forever once you're on them, or is there a limited period?
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Lucas Shelton, MD: For patients in that secondary prevention category
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For most scenarios, it is an indefinite benefit.
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Just because once you have established disease, the benefit
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of statin is always there in terms of preventing future events, future
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development of arterial disease.
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So it is, it's most of the time, you know, in my relatively short
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career, I've learned there's never an absolute in medicine.
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Uh, but for speaking in general terms, indefinite benefit.
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Going back to the primary prevention category of patients, once patients
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approach age of 75 and 80, around that neighborhood of age, it becomes more of a
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dis-discussion of, "Hey, you know, there, there's not as much clear evidence to
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continue statin beyond this age bracket."
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Uh, it becomes a very personalized discussion as it is anyway, but even more
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so because if you have a patient who, you expect to have a life expectancy,
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you know, still over 10 years and, uh, patient still wants to have the benefit
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of, of statin, you know, that those are the kinds of things that can maybe kind
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of push that discussion into, well, maybe let's stay on the statin for benefit.
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But if you have a different scenario, uh, you don't always have to just
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stay on the statin, for those patients around that age group.
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So c- I think I would just summarize it as in primary prevention around
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that age, it just becomes even more so of a personalized discussion on
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continuing or stopping the medicine.
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Amanda (Host): And since this is one of your specialties, how
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would you rate how effective the statin therapy is in most cases?
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Lucas Shelton, MD: with secondary prevention,
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I can't stress enough how effective statins are at preventing future
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events and preventing death from cardiovascular disease.
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Those are two very important outcomes.
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Those are, with any study in medicine, those are two of the biggest types
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of outcomes we can, can look at.
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So, I, I can't even put a high enough quantity on how much I believe in them,
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uh, to help prevent future events.
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And then to answer your question for patients in the primary prevention
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category, the effectiveness of statin depends on how much risk a patient
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has before they start the statin.
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And I think very relevant to this podcast discussion today is just in
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March of this year, American College of Cardiology, along with the American
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Heart Association and some other cardiovascular societies, hot off the
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press, updated their lipid management guidelines that hadn't been updated,
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I believe, in about eight years or so.
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So there are brand-new guidelines in terms of helping us as prescribers
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quantify risk in terms of deciding when, to start a statin for someone who doesn't
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have any history of any of the things in the secondary prevention category.
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Uh, there's a much more accurate calculator we can use.
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It's called the PREVENT, atherosclerotic cardiovascular disease
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risk score, ASCVD, uh, for short.
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So a brand-new calculator we can use.
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It's based off a much more modern millions of patients group of people compared to
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the old calculator called the, uh, pooled cohort equation that took data from
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patients in a much smaller scale from the 1940s to I think about the 1980s.
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So the new calculator and the new guidelines, it's a much more modern
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approach to quantifying cardiovascular risk to help us as prescribers, decide
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on who would benefit from statins.
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So coming back to answer your question, how effective do I believe
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statins are in primary prevention?
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I think very effective, but it has to be for the right patient, so
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they have to have a high enough risk on this new calculator.
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As prescribers, we need to be using this updated risk calculator called
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the PREVENT ASCVD risk calculator.
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Part of the reason I wanted to do this podcast is to help kind of get the word
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out, uh, that these guidelines are out.
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We should be using this new calculator.
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So, uh, for the right patient with that calculator, a very clear benefit as well
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Amanda (Host): Mm-hmm.
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Mm-hmm.
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And with the guidelines changing, it makes me wonder, are there common misconceptions
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of statins that you encounter?
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And if so, how do you address those?
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Lucas Shelton, MD: Absolutely.
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in the social media age, information, as you know, spreads lightning quick.
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To name a few misconceptions, uh, one I hear commonly is that patients have a fear
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of statins causing dementia or trouble with thinking called cognitive impairment.
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Uh, just to be blunt and very, uh, straight to the
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point, they do not cause that.
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Uh, there's no evidence that they cause that.
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just to name a few other misconceptions I've seen, uh, in social media and, um,
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in discussions with patients, fears of, uh, kidney problems, kidney disease.
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There's no evidence of that.
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and then in terms of, I've even seen like, do statins cause cancer?
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There's no, no evidence of those things.
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So, but to answer your question, how do I have that discussion?
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I certainly welcome my patients to talk to me about things they've heard.
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I believe that statins are so beneficial that I believe if I welcome
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those conversations, I can, in a very loving way, just share with my
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patients, "Hey, this is what I know.
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This is what I know the evidence shows."
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And just, you know, talk about those, maybe misconceptions or things they've
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heard, um, just like maybe with any other medicine, and just have that conversation.
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'Cause in primary care, a big part of my job is, uh, handling those misconceptions
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and still guiding the patient to the best, uh, treatment pathway, uh, for them
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Amanda (Host): Right.
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And you were saying statins are very right for the right person.
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If someone listening right now has been told they might need a statin,
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what questions should they ask their primary care provider, or what's a
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good first step for exploring that?
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Lucas Shelton, MD: I would say make an appointment with your primary care
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and, uh, we can take it from there.
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It would start with checking a few things that kind of go into that,
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calculator I was talking about.
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so some things that go into the calculator would be the patient's
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blood pressure, any history of diabetes, any history of smoking or,
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current smoking, uh, patient's age.
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So we can use all these things, and we have to, to,
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get the cardiovascular risk.
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And the cardiovascular risk, it's a population-based calculation.
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Our job as prescribers is to individualize the treatment.
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So, you know, as an example, there might be a patient who is on the lower end of
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risk by the calculator, but they may have certain other things in their history
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or certain other chronic conditions that also add to cardiovascular risk.
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And that's our job to recognize those things and still say, "Hey, even
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though you're on the lower side of this calculator, maybe you actually
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would still benefit, from a statin."
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So it can definitely be a nuanced discussion, but that's, that's our
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expertise, uh, and our job is to kind of talk through those things with patients.
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So to answer your question, encourage patients to make an appointment and
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have the conversation, get some lab work done, and get the risk calculator, uh,
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number, and then kind of go from there
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Amanda (Host): Well, Dr.
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Sheldon, thank you so much for explaining what statin medications
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are, when they're used, and how they can help protect heart health
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Lucas Shelton, MD: Absolutely.
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Thank you for having me.
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and appreciative to use this platform to, uh, kind of at least get this
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new, new guidelines out and, and some of the things that go with it.
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So I appreciate it
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Amanda (Host): Dr.
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Lucas Shelton is medical director, UK Healthcare Primary Care Frankfort.
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For more information, visit ukhealthcare.uky.edu.
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