Statins: The Good, the Bad, and the Unknown

Clinicians Are Talking About Statins

Gordon H. Sun, MD, MS

Disclosures

October 10, 2014

In This Article

The "Statin-Lifestyle Interaction"

The benefits of lifestyle modifications to prevent CVD are well known, and several Cochrane reviews[22,23] have demonstrated the value of dietary advice and increased consumption of fruits and vegetables for primary prevention. The ACC/AHA guideline authors[1] explicitly state that "a healthy lifestyle is the foundation for cardiovascular health." Moreover, no randomized trial has compared statins with beneficial lifestyle changes and found that statins had a superior or additive effect on clinical outcomes.[24] A 2003 randomized trial[25] comparing the effects of a cholesterol-lowering diet with lovastatin (Mevacor®, Altoprev®) on serum lipid profiles found that both interventions were equally effective in reducing cholesterol.

That being said, Dr Mandrola worried that any benefit of statin use might be attenuated by the impact of an unhealthy lifestyle, a concern echoed by many Medscape readers. Typical responses included one by a dietitian, who remarked, "I see so many patients who think taking a statin is an insurance policy against disease, and this gives them license to not make any lifestyle changes." Another physician wondered how long lifestyle modification should be attempted, asking whether doctors should "have exercise equipment in their offices and a nutritionist on site instead of a statin and prescription pad."

The evidence on whether patients taking statins adhere to healthier lifestyles is conflicting. Population-based studies[26,27] indicate that patients initiating statins were more likely to receive other preventive services (eg, influenza vaccinations) and participate in health-promoting behaviors compared with non-users. However, another population-based study, this one conducted in central Denmark, found that the average current statin user was more likely to have a healthy diet but also less likely to exercise regularly and to have never smoked compared with non-users.[28]

To that end, one of Dr Mandrola's cited references warrants further explanation. Lee and colleagues[29] published a multicenter community-based prospective cohort study of 5995 elderly men participating in the Osteoporotic Fractures in Men Study. The study found that after controlling for medical history and other potential confounders, statin use was associated with modestly lower physical activity. The study authors speculated that statin- or exercise-related myopathy, or general muscular fatigue, were possible explanations. This brings up another unique point: A statin user may be less inclined toward physical activity not because of lack of patient (or provider) motivation but because the patient's ability to exercise might be compromised by statin-induced muscle damage.

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