Features January 2019 Issue

When Statins Are Not the Answer

There are other medications and methods to help lower cholesterol.

Cholesterol-lowering statins are a "must" for people with coronary artery disease (CAD) or its risk factors. These drugs are considered the gold standard for slowing the progression of plaque in the coronary arteries and reducing the risk of heart attack and stroke.

But statins don't always bring LDL cholesterol levels down far enough to be protective. Some people do not tolerate statins well and stop taking the drug if they experience leg cramps or other side effects. If you fall into one of these categories, there are other medications that can safely lower your cholesterol levels and risk for a cardiovascular event.

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"Statins remain the gold standard, but clinical trials have helped us understand which medications provide the best chance of preventing heart attack and stroke if an alternative or addition to statins is needed," says Cleveland Clinic preventive cardiologist Luke Laffin, MD.

How Low Is Low Enough?

Doctors used to set a goal of lowering cholesterol to a specific number. For patients with heart disease, this was 100 mg/dL or 70 mg/dL, depending on their risk. But thinking has changed, and with it, how these medications are used.

"Guidelines now recommend reducing LDL cholesterol by a certain percentage based on risk," says Dr. Laffin.

For patients at elevated risk of heart attack or stroke, adding ezetimibe (Zetia®) to statin therapy can lower LDL an additional 15 to 20 percent.

For patients with very high cholesterol levels, adding a PCSK9 inhibitor (Repatha®, Praluent®) instead of ezetimibe can cause their cholesterol to drop an additional 50 percent.

Both drugs are well tolerated, but their exorbitant cost has limited their use. That may soon change. "More insurance carriers are covering these drugs, now that there's good data on their ability to lower cardiovascular events," says Dr. Laffin.

The Role of Diet and Exercise

A heart-healthy diet and regular exercise can help lower cardiovascular risk, but lifestyle changes rarely have a large effect on LDL levels.

"You are unlikely to see a significant reduction in cholesterol without medications," says Dr.Laffin.

That being said, the Dietary Approaches to Stop Hypertension (DASH) diet has been shown to lower LDL by as much as 11 mg/dL-nearly as much as ezetimibe. The DASH diet emphasizes fruits, vegetables, low-fat dairy, lean meats and fish, whole grains, nuts, legumes and heart-healthy fats and is low in sodium, saturated fat and sugar.

Gone with the Wind

In the past, niacin, fenofibrates, bile acid sequestrants and fish oil were widely used to help normalize blood lipid levels. Most have fallen out of favor. But in November, physicians were wowed when a key study revealed that prescription-strength doses of eicosapentaenoic acid (EPA), a form of omega-3 fish oil, reduced the risk of cardiovascular death, heart attack, stroke, revascularization and unstable angina by 25 percent in patients with CAD or diabetes and high triglyceride levels.

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