Statins are a class of medications designed to lower levels of cholesterol in the blood, particularly low-density lipoprotein (LDL) cholesterol. These medications work by inhibiting an enzyme in the liver involved in cholesterol production, reducing the amount the body makes and helping remove existing cholesterol from the blood. The primary aim of statin therapy is to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) events, such as heart attacks and strokes, which can occur when cholesterol builds up in the arteries. Major health organizations have recently updated their guidelines for prescribing these medications.
The Shift in Recommendation Philosophy
The approach to recommending statin therapy has undergone a significant change, moving away from a primary focus on achieving a specific LDL cholesterol target. Older guidelines often emphasized a “treat-to-target” strategy, aiming to lower LDL cholesterol to a predetermined number. The updated philosophy, particularly from organizations like the American College of Cardiology (ACC) and the American Heart Association (AHA), now centers on a more comprehensive assessment of an individual’s overall 10-year risk of developing ASCVD.
This model, often termed “treat-the-person’s-risk,” considers a broader range of factors beyond just LDL cholesterol levels. While LDL cholesterol remains an important component, it is now evaluated alongside other variables to create a more personalized recommendation for statin use. This shift acknowledges that cardiovascular risk is multifaceted and requires a holistic view rather than isolating a single biomarker. The goal is to identify individuals who stand to benefit most from statin therapy based on their absolute risk of experiencing a cardiovascular event.
Who Is Recommended for Statins Now
Under the current guidelines, statin therapy is recommended for several distinct groups of individuals, reflecting a stratified approach to cardiovascular disease prevention. One primary group includes people with existing atherosclerotic cardiovascular disease (ASCVD), such as those with a history of heart attack, stroke, stable or unstable angina, or peripheral artery disease. These individuals are considered at high risk for future events and benefit from high-intensity statin therapy to significantly reduce their LDL cholesterol levels by 50% or more.
Another clear recommendation applies to individuals with very high levels of LDL cholesterol, specifically those with a primary elevation of LDL-C levels of 190 mg/dL or greater. For these patients, statin therapy, often at a high intensity, is initiated without the need for a formal 10-year ASCVD risk assessment, as their cholesterol levels alone indicate a substantial risk. Similarly, adults aged 40 to 75 years who have diabetes mellitus are recommended for at least moderate-intensity statin therapy, even if their LDL cholesterol is between 70 and 189 mg/dL.
Beyond these specific conditions, statins are also recommended for adults aged 40 to 75 years who do not have existing ASCVD or diabetes but have an elevated estimated 10-year ASCVD risk. The guidelines categorize this risk into tiers: intermediate risk is 7.5% to less than 20%, while a high risk is 20% or greater. For those in the intermediate-risk category, moderate-intensity statin therapy is considered, while high-intensity statin therapy is recommended for those at high risk.
Key Factors in Your Personal Risk Assessment
Understanding your personal risk for atherosclerotic cardiovascular disease involves evaluating several specific factors that contribute to your 10-year ASCVD risk score. This score, calculated using tools like the “ASCVD Risk Estimator Plus,” integrates various inputs to provide an estimate of your likelihood of experiencing a heart attack or stroke within the next decade.
Factors include your age, sex, and race. Your cholesterol levels (total and HDL) are included. Systolic blood pressure (and whether it’s treated), and diabetes status are also included. Your smoking status is a key factor in the risk assessment. These combined factors allow healthcare providers to quantify your individual risk and guide discussions about preventive strategies, including the potential role of statin therapy.
The Role of Lifestyle and Shared Decision-Making
The updated guidelines emphasize that preventing cardiovascular disease is not solely about medication; it also involves a collaborative discussion between patients and their healthcare providers. This concept, known as “shared decision-making,” encourages a dialogue where the potential benefits and risks of statin therapy are discussed, especially for individuals in the intermediate-risk category. Patients’ values and preferences play a role in this conversation, ensuring that treatment decisions align with their circumstances and goals.
Alongside pharmacological interventions, lifestyle modifications remain the primary element for preventing cardiovascular disease across all risk levels. A heart-healthy lifestyle includes regular physical activity, aiming for at least 150 minutes of moderate-intensity aerobic activity per week. Adopting a balanced diet rich in vegetables, fruits, whole grains, lean protein, and healthy fats, while limiting processed foods, added sugars, and unhealthy fats, is also recommended.
Stopping smoking is an important lifestyle change for reducing cardiovascular risk, and weight management also contributes to heart health. These lifestyle changes are considered the primary steps in managing cardiovascular risk, regardless of whether statin therapy is initiated.