Ask the Doctors - Should I take a statin just in case?

Dr. Robert Ashley, MD

Dear Doctor: A news report recently said that statins are underused. I'm 50 with normal cholesterol. Should I take one just in case?

Dear Reader: Statins, which are a type of cholesterol-lowering medication, have consistently shown benefit in reducing the risk of heart attacks and strokes in people who have had a previous heart attack or angina. This benefit is called secondary prevention. Statins have also shown benefit in people with risk factors for heart disease who have never had a heart attack; smokers; and people with diabetes, hypertension or a family history of heart disease. This is called primary prevention.

In people like yourself, the potential benefit of statin use is not as clear-cut. So, first, let's look at the Jupiter study, published in 2008. The 17,802 people in this study had normal cholesterol levels -- that is, an LDL score (for low-density lipoprotein, the so-called "bad cholesterol") of less than 130 -- but they had an elevated level of highly sensitive C-reactive protein (CRP), a marker for both inflammation and a heightened risk of coronary artery disease.

Researchers divided participants into two groups, with one group taking a daily placebo and the other group taking a daily 20-milligram dose of rosuvastatin. The study was stopped in less than two years because of the significant benefit seen in the group that took the statin.

The study authors found a 44 percent decrease in deaths from heart attacks and strokes and a 20 percent decrease in the total death rate among the group who took the statin. Not only did participants who took rosuvastatin show a reduction in cholesterol, they also showed a decrease in their levels of highly sensitive CRP. That suggests that statins reduce both cholesterol and the inflammation that may lead to vascular disease.

Now let's look at what to consider if your CRP level is normal and you have normal cholesterol. A 2001 study in the New England Journal of Medicine followed 6,605 men and women in Texas who had either normal CRP levels or abnormal CRP levels. One group was given a statin, called lovastatin, and the other group was given a placebo. Although there was a benefit seen with lovastatin among those who had an elevated CRP level, the benefit was not seen in those who had a normal CRP level.

One conclusion from the data is that if you have normal cholesterol and no other risk factors, you should have your doctor check your levels of highly sensitive CRP. If the CRP is persistently elevated, then there is likely benefit to a cholesterol-lowering medication. One word of caution, however: If you have inflammation related to either infection or an autoimmune condition, the CRP will be elevated because of those conditions and therefore won't be a reliable marker.

Doctors currently assess the need for statins by looking at risk calculators. These risk calculators assess an individual's risk of having a heart attack over the next 10 years. Some doctors recommend that people start statins if their 10-year risk of a heart attack is 7.5 percent. So if you're a healthy 55-year-old man with normal cholesterol and a blood pressure of 125/70, your calculated risk would be 7.83 percent -- and many doctors would recommend a statin. However, the science behind the risk calculator is poor, with a large Kaiser Permanente study of 307,000 people showing that it may significantly overestimate risk.

That finding emphasizes the need for the CRP test. If that test is normal, a statin would be unlikely to provide any benefit to you.

Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.