Amanda Wilde (Host): Welcome to UK HealthCast, a podcast presented by UK HealthCare. We're talking about statin therapy with Dr. Lucas Shelton, Medical Director of UK HealthCare Primary Care Frankfurt. I'm your host, Amanda Wilde. Dr. Shelton, welcome to the podcast. Thank you so much for being here

Lucas Shelton, MD: Yeah. Thank you for having me. Um, I'm excited to share what I know about statins. Uh, it's a very relevant topic in, in medicine right now

Amanda Wilde (Host): And very widely used. So first of all, what exactly are statins?

Lucas Shelton, MD: statins are a medication, uh, that treat, cholesterol in, in terms of lowering certain types of cholesterol in our bodies. They, they act on the pathway of where cholesterol is, processed and synthesized in the liver. And the part of the pathway they act on kind of leads to a downstream effect of decreasing the amount of cholesterol that is most associated with, uh, things like heart attack and stroke

Amanda Wilde (Host): When are statins indicated?

Lucas Shelton, MD: to answer that question, we have to break patients up into two different, categories. Those two categories are called primary prevention and secondary prevention. Uh, so I think answering the question comes down to which bucket do I as a patient fit into if I have high cholesterol?

I'll start with actually the secondary prevention category.

Uh, so people in general will be in the secondary prevention category if you've had a cardiovascular event, uh, such as a heart attack or an ischemic stroke, or what is often referred to as a mini stroke.

So those events, uh, define individuals as having what we call atherosclerotic cardiovascular events. Other conditions that can place patients into the secondary prevention category, really include arterial disease. And so arterial disease can be peripheral in the extremities of the arms or the legs.

Arterial disease can be in the coronary arteries. Uh, those are the arteries that supply blood flow to the heart itself. And then the other kind of arterial disease that can happen is even in the abdomen and also up in the head and neck within the carotid artery. So

arterial disease is cholesterol plaque buildup within the walls of arteries.

So arterial disease and then those events I alluded to just a little bit ago, if patients have any of those conditions or that history of event, no matter what the cholesterol panel looks like for that patient, statins have proven benefit for those patients. So that's secondary prevention. Primary prevention includes patients who have never had a cardiovascular event like what I just mentioned, and they don't have any known arterial disease.

And so that's more of a patient that I en-encounter very commonly in my primary care practice. That's a patient who comes in for annual labs, and I, I check so many, it's called a lipid panel. you know, lipid panels give me a readout on the different types of cholesterol within the bloodstream. And that's a patient who we sit down together, we are talking about how the cholesterol looks and the overall cardiovascular risk.

And if you have enough risk, if you're in the primary prevention category, statins can be indicated as well. So those are the two main categories of people who can benefit from statins

Amanda Wilde (Host): So in primary care, this is when you first start thinking this patient may need a statin if they have one of these health conditions or risk factors. What are the benefits of statins? How, and how do they work in the body?

Lucas Shelton, MD: So the benefits of statins in the secondary prevention group of patients, they help prevent future events like future heart attacks and future strokes. They are proven to decrease the chances of those things happening in the future, which we obviously want to decrease the chances of those. They decrease the chance of death from, uh, cardiovascular events and disease.

Those are two main categories of benefit that's proven within the secondary prevention group of patients. And then within the primary prevention, part of the reason it's named primary prevention is for patients who have enough risk, who have never had an event, there's evidence, good evidence, that shows that statins help decrease the chance of the first stroke, heart attack, or arterial disease, uh, development.

So, um, it's all about preventing the first event if patients have never had one before. And statins are just working there in the liver, to decrease that type of cholesterol called the LDL that's most associated with these things like heart attack and stroke

Amanda Wilde (Host): Are there any side effects to statins?

Lucas Shelton, MD: Yes. Most common, uh, side effect with statins have to do with muscle. In clinical practice, up to about 10% of patients can experience what we call myalgias, uh, which is a muscle ache or a muscle pain. It has to do with the way that, uh, statins can also work within muscle tissue Randomized control trials, which are the highest quality type of study, have actually shown that most of the patients who experience muscle aches from statins, that is actually attributable to what's called a nocebo effect, which means that patients can go on to taking a statin almost with the expectation of having a side effect.

And so it's not actually the effect of the medicine itself, it's, um, more of a certain type of placebo that we call nocebo. but I don't mean to say at all that there's not true muscle issues that go on sometimes. There, there are, and I, you know, I tell my patients, "Hey, if you have muscle aches, muscle cramps with this medicine, please let me know.

We can always try a different statin or an alternate medicine." Uh, so that, that's one of the most common side effects. There are some more rare side effects. Uh, one of the things that we'll be seeing in literature, uh, is a very small chance of actually the development of diabetes, uh, with statin medications.

0.2% per year is the rate of developing diabetes with, uh, statin medication. But the way I always kinda discuss about that with my patients is, let's say we have a patient who has pre-diabetes, and they are almost at the point of having diabetes. And let's say they're, they're not on a statin, and their cholesterol is, is to the point where I think that they would have benefit from being on a statin. I would never hold off recommending a statin for fear of pushing that patient into diabetes, because the overall cardiovascular benefits of statin therapy, if I feel like it's warranted, far outweighs that small chance of developing diabetes. And I'll kinda finish that thought with this. Diabetes in and of itself is such a risk factor for cardiovascular disease that, most patients over 40 with diabetes need a statin anyway just by the fact of having diabetes. So, answer to that question, there's a very, very rare, liver toxicity that can happen from statins.

It is so rare that, About 13 or 14 years ago, the recommendation to trend liver enzymes while being on statin actually went away. There's no good evidence to do that now, uh, but very, very rare. I believe the exact percentage is 0.001% of the severe liver toxicity Now there are certain liver conditions where we want to be cognizant as prescribers of, "Hey, do we need to maybe hold off on the statin?"

But that is our responsibility, uh, as prescribers to have that discussion with patients

Amanda Wilde (Host): Well, thank you for putting the side effects in perspective. When we talk about statin therapy, are statins something you take forever once you're on them, or is there a limited period?

Lucas Shelton, MD: For patients in that secondary prevention category

For most scenarios, it is an indefinite benefit. Just because once you have established disease, the benefit of statin is always there in terms of preventing future events, future development of arterial disease. So it is, it's most of the time, you know, in my relatively short career, I've learned there's never an absolute in medicine.

Uh, but for speaking in general terms, indefinite benefit. Going back to the primary prevention category of patients, once patients approach age of 75 and 80, around that neighborhood of age, it becomes more of a dis-discussion of, "Hey, you know, there, there's not as much clear evidence to continue statin beyond this age bracket."

Uh, it becomes a very personalized discussion as it is anyway, but even more so because if you have a patient who, you expect to have a life expectancy, you know, still over 10 years and, uh, patient still wants to have the benefit of, of statin, you know, that those are the kinds of things that can maybe kind of push that discussion into, well, maybe let's stay on the statin for benefit.

But if you have a different scenario, uh, you don't always have to just stay on the statin, for those patients around that age group. So c- I think I would just summarize it as in primary prevention around that age, it just becomes even more so of a personalized discussion on continuing or stopping the medicine.

Amanda Wilde (Host): And since this is one of your specialties, how would you rate how effective the statin therapy is in most cases?

Lucas Shelton, MD: with secondary prevention, I can't stress enough how effective statins are at preventing future events and preventing death from cardiovascular disease. Those are two very important outcomes. Those are, with any study in medicine, those are two of the biggest types of outcomes we can, can look at.

So, I, I can't even put a high enough quantity on how much I believe in them, uh, to help prevent future events. And then to answer your question for patients in the primary prevention category, the effectiveness of statin depends on how much risk a patient has before they start the statin.

And I think very relevant to this podcast discussion today is just in March of this year, American College of Cardiology, along with the American Heart Association and some other cardiovascular societies, hot off the press, updated their lipid management guidelines that hadn't been updated, I believe, in about eight years or so.

So there are brand-new guidelines in terms of helping us as prescribers quantify risk in terms of deciding when, to start a statin for someone who doesn't have any history of any of the things in the secondary prevention category. Uh, there's a much more accurate calculator we can use. It's called the PREVENT, atherosclerotic cardiovascular disease risk score, ASCVD, uh, for short.

So a brand-new calculator we can use. It's based off a much more modern millions of patients group of people compared to the old calculator called the, uh, pooled cohort equation that took data from patients in a much smaller scale from the 1940s to I think about the 1980s. So the new calculator and the new guidelines, it's a much more modern approach to quantifying cardiovascular risk to help us as prescribers, decide on who would benefit from statins.

So coming back to answer your question, how effective do I believe statins are in primary prevention? I think very effective, but it has to be for the right patient, so they have to have a high enough risk on this new calculator. As prescribers, we need to be using this updated risk calculator called the PREVENT ASCVD risk calculator.

Part of the reason I wanted to do this podcast is to help kind of get the word out, uh, that these guidelines are out. We should be using this new calculator. So, uh, for the right patient with that calculator, a very clear benefit as well

Amanda Wilde (Host): Mm-hmm. Mm-hmm. And with the guidelines changing, it makes me wonder, are there common misconceptions of statins that you encounter? And if so, how do you address those?

Lucas Shelton, MD: Absolutely. in the social media age, information, as you know, spreads lightning quick.

To name a few misconceptions, uh, one I hear commonly is that patients have a fear of statins causing dementia or trouble with thinking called cognitive impairment. Uh, just to be blunt and very, uh, straight to the point, they do not cause that.

Uh, there's no evidence that they cause that. just to name a few other misconceptions I've seen, uh, in social media and, um, in discussions with patients, fears of, uh, kidney problems, kidney disease. There's no evidence of that. and then in terms of, I've even seen like, do statins cause cancer?

There's no, no evidence of those things. So, but to answer your question, how do I have that discussion? I certainly welcome my patients to talk to me about things they've heard. I believe that statins are so beneficial that I believe if I welcome those conversations, I can, in a very loving way, just share with my patients, "Hey, this is what I know.

This is what I know the evidence shows." And just, you know, talk about those, maybe misconceptions or things they've heard, um, just like maybe with any other medicine, and just have that conversation. 'Cause in primary care, a big part of my job is, uh, handling those misconceptions and still guiding the patient to the best, uh, treatment pathway, uh, for them

Amanda Wilde (Host): Right. And you were saying statins are very right for the right person. If someone listening right now has been told they might need a statin, what questions should they ask their primary care provider, or what's a good first step for exploring that?

Lucas Shelton, MD: I would say make an appointment with your primary care and, uh, we can take it from there. It would start with checking a few things that kind of go into that, calculator I was talking about. so some things that go into the calculator would be the patient's blood pressure, any history of diabetes, any history of smoking or, current smoking, uh, patient's age.

So we can use all these things, and we have to, to,

get the cardiovascular risk. And the cardiovascular risk, it's a population-based calculation. Our job as prescribers is to individualize the treatment. So, you know, as an example, there might be a patient who is on the lower end of risk by the calculator, but they may have certain other things in their history or certain other chronic conditions that also add to cardiovascular risk.

And that's our job to recognize those things and still say, "Hey, even though you're on the lower side of this calculator, maybe you actually would still benefit, from a statin." So it can definitely be a nuanced discussion, but that's, that's our expertise, uh, and our job is to kind of talk through those things with patients.

So to answer your question, encourage patients to make an appointment and have the conversation, get some lab work done, and get the risk calculator, uh, number, and then kind of go from there

Amanda Wilde (Host): Well, Dr. Sheldon, thank you so much for explaining what statin medications are, when they're used, and how they can help protect heart health

Lucas Shelton, MD: Absolutely. Thank you for having me. and appreciative to use this platform to, uh, kind of at least get this new, new guidelines out and, and some of the things that go with it. So I appreciate it

Amanda Wilde (Host): Dr. Lucas Shelton is medical director, UK HealthCare Primary Care Frankfort. For more information, visit ukhealthcare.uky.edu. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening to UK HealthCast, a podcast from UK HealthCare