Only 35% of people eligible for statins use them, study shows. How do you know if you should be on them?

About 86 million adults in the U.S. have high cholesterol, a condition that raises the risk for heart disease and stroke. Despite these high numbers, only 55% of American adults who could benefit from cholesterol-lowering medication actually take it.

While there are are several medications that can help, a common class of cholesterol-lowering drugs is statins. However, you’re not alone if you’re not exactly sure how they work, when to go on them and whether there are potential side effects you should be concerned about. So what’s the deal with statins and how safe are they? Cardiologists break it down.

How do statins work exactly?

The main function of statins is to reduce your cholesterol. “Statins work in the liver to block the pathway that makes cholesterol,” Dr. Blair Suter, a cardiologist at The Ohio State University Wexner Medical Center, tells Yahoo Life.

Your liver responds to statins by taking up cholesterol particles in the blood more easily — which leaves less cholesterol in your blood, Dr. Yu-Ming Ni, cardiologist and lipidologist at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, Calif., tells Yahoo Life. (Higher levels of cholesterol in the blood can damage your arteries, raising the risk of heart attack or stroke, he explains.)

The more cholesterol that is in your blood, the faster it gets incorporated into plaques along the walls of blood vessels, Dr. Alexander C. Fanaroff, assistant professor of medicine in the division of cardiovascular medicine at the University of Pennsylvania, tells Yahoo Life. “If the plaques grow too large, they can block blood flow to the heart or brain, causing a heart attack or stroke,” he says. “Therefore, lowering cholesterol with statins can help reduce the risk of a heart attack or stroke.”

“There is also some data that statins reduce inflammation,” Ni says, noting that this can also help lower your risk of heart attacks or strokes.

Who needs statins?

The U.S. Preventive Services Task Force (USPSTF), American College of Cardiology (ACC) and American Heart Association (AHA) say that the following groups of people may benefit from statins:

• People with one or more cardiovascular disease risk factors and a higher 10-year risk of having a heart attack. That includes people who have diabetes, high cholesterol or high blood pressure, as well as people who smoke.

• People who have cardiovascular disease. These are patients with heart disease linked to hardened arteries, including those who have had heart attacks or strokes from blockages in a blood vessel, mini-strokes, peripheral artery disease or surgery to open or replace coronary arteries.

• People with high LDL (“bad”) cholesterol. This includes adults with LDL cholesterol levels of 190 mg/dL or higher.

• Adults with both diabetes and high cholesterol. This includes adults age 40 to 75 who have diabetes and an LDL cholesterol level between 70 and 189 mg/dL.

“Statins reduce the risk of heart attack, stroke or cardiovascular death by about 30%,” Fanaroff says. This means a person’s 10-year risk is 7.5% if they’re not taking statins — and the medication would reduce that risk to around 5%. “If a person’s risk is higher, like 25%, statins reduce that risk to around 17%,” Fanaroff points out.

Are statins safe?

While doctors agree that statins are safe and well tolerated by most people, some patients are apprehensive about taking them. “People may be concerned about starting statins due to potential side effects related to the liver, muscles and cognitive impairment,” Suter says.

Those often stem from a 2012 warning from the Food and Drug Administration, which stated that people who used statins reported dealing with a range of health issues, including:

• Short-term memory loss and confusion that went away when people stopped using the drug

• Increases in blood sugar levels

• In rare cases, serious liver problems

But, again, the data has been mixed. “Research has been conflicting and controversial regarding all of these side effects,” Suter says. A 2021 study published in the Journal of the American College of Cardiology analyzed data on statin use in 18,446 people ages 65 and up. The researchers found that people who took statins weren’t any more likely than people who didn’t use the medications to have dementia over the five-year study period. There were also no differences in memory, language and executive function.

Another study, this one published in the journal Scientific Reports, analyzed data from 55,114 people taking statins and compared them to 245,731 people who weren’t on the medications. Participants were measured for reaction time, working memory and fluid intelligence (the ability to reason and think flexibly) at the beginning of the study, as well as during two follow-ups within five to 10 years. The researchers found that older people who took statins had better reaction times and fluid intelligence, while people who were younger had an improvement in fluid intelligence but had decreases in working memory. As a result, the researchers concluded that the impact of statins may vary by age.

For blood sugar levels, research shows that in patients with a high risk for atherosclerotic disease — a hardening of the arteries caused by a buildup of plaque — the benefits of statin use outweigh the risk of new-onset diabetes. That benefit-risk ratio is less clear — and should be discussed with a health care provider — when it comes to patients who don’t have diabetes and have either zero or only one risk factor for atherosclerotic disease.

As for liver disease, a 2023 study of more than 1.7 million people published in JAMA Network Open found that regular use of statins was linked with a 15% lower risk of developing liver disease and a 28% lower risk of dying from a liver-related issue compared to people who didn’t take the drugs. There was also a 74% lowered risk of developing liver cancer in people who used statins regularly.

What are the possible side effects of statins?

While there are more serious potential side effects that are still being explored, there are some minor issues statin users may experience.

“The most common side effect of statins is muscle aches,” Dr. Samuel Kim, preventive cardiologist at NewYork-Presbyterian/Weill Cornell Medical Center, tells Yahoo Life. Kim says this tends to be more common in clinical practice than large clinical trials suggest. However, Kim says side effects tend to get better with time and by tweaking dosages. Side effects can also include fatigue and increases in blood sugar, but these are less common, he says.

“Even for patients with side effects, when they lower the dosage of statin or re-trial the medication after a temporary break, they are often able to tolerate the medication,” Kim says.

Why don’t more doctors prescribe them?

A study published in the Annals of Internal Medicine in early December analyzed National Health and Nutrition Examination Survey data from 1999 to 2018 and found that while the use of statins to prevent cardiovascular issues increased during that time, only 35% of people who are eligible for the medications actually use them.

The researchers theorized that many doctors don’t have time to do the required multistep risk calculation for prescribing statins, so they just don’t prescribe the medications. “When you give primary care providers hypothetical patient scenarios and ask if these patients should be prescribed statins, the primary care providers tend to closely follow the guidelines and prescribe statins to eligible people,” Fanaroff says. “To me, this suggests that more doctors don’t prescribe statins because they are too busy in short clinic appointments to attend to everything a patient needs, and preventive care can be sacrificed to take care of more urgent concerns.”

Fanaroff stresses that this isn’t a case of doctors being lazy. “In one study, researchers showed that it would take 26.7 hours for primary care providers to take care of all of the acute and preventive needs of patients they see in a single day, which is obviously impossible,” he says. “Research from our group and others shows the promise of involving other members of the health care team, like nurses and pharmacists, to help prescribe statins to the appropriate people.”

But Ni says the issue is more complicated than available time. “There is an abundance of misinformation regarding statins,” he says. “I have heard patients complain that cholesterol is not important for reducing heart disease, that statins damage the liver and cause dementia and even that doctors are in cahoots with pharmaceutical companies to make money off statins — none of these are true,” he says.

Kim agrees. “Statins have proven to be a very safe medication and well tolerated in the majority of the population,” he says. “There should be a mutual discussion between a provider and patient surrounding the risks and benefits. Statins still remain vastly underutilized.”

Ni stresses that statins are inexpensive, too. “They are one of the most cost-effective treatments we have for fighting the No. 1 killer in America: heart disease,” he says.