Statins remain our safest and most effective drug for primary and secondary prevention of coronary artery disease. However, a cult of statin deniers has taken hold on the internet and their efforts often result in patients inappropriately stopping statins, an outcome which can have lethal consequences.
Early in the pandemic a patient of mine in his late 80s who had been successfully maintained for a decade on medical therapy for a totally occluded left anterior descending coronary artery presented with chest pain to a hospital ER. Testing revealed he had suffered a non ST elevation myocardial infarction and a subsequent catheterization showed a 99% blockage of his right coronary artery which was successfully stented.
When I reviewed his labs I noted that his LDL cholesterol which had been at goal for 10 years on statin therapy had doubled since we last checked it. It turns out the patient had stopped his statin (after 10 years of side-effect-free usage) 3 months earlier (without telling me) because a family member had told him the drug was dangerous.
Misinformation is even more rampant since the onset of COVID-19 and there has been much speculation that statins might worsen outcomes of the disease thus we may anticipate even more well-intentioned advice to patients to stop their prescribed medications.
COVID-19 and the Heart
COVID-19 compared to other respiratory viruses seems to be associated with more significant cardiovascular complications. Proposed mechanisms include inflammation, myocardial injury and thrombosis.
In addition, patients most likely to suffer severe COVID-19 are those with pre-existing cardiovascular disease who benefit most from statins.
Could Statins Reduce COVID-19 Risks?
Theoretically, statins could be cardioprotective in COVID-19 due to their effects on lipid-lowering and plaque stabilization along with documented anti-inflammatory, immunomodulatory and antithrombotic effects. In addition, statins inhibit a pathway (MYD88) which in SARS-CoV 1 was associated with intense inflammation and poor response.
Observational Data Show Statin Benefit
Fortunately, the observational data in this area strongly show that taking statins is associated with a lower risk of fatal or severe COVID-19. A large retrospective study of 14 thousand COVID-19 cases from China showed a 42% lower death rate in statin users compared to propensity-matched non-users.
(What any of this has to do with surfing is unclear to me.)
This study also showed that the benefit of statins may be mediated by reduced inflammation as inflammatory markers (CRP, IL-6 and WBC count) were significantly lower in statin users.
The latest evidence on this topic comes from a meta-analysis published Aug 4 in the American Journal of Cardiology which suggested a reduction in fatal or severe disease by 30% in those taking statins versus non-statin takers.
Like all observational data, we must view these findings as preliminary. At a minimum though we can take comfort that there is no signal that statins worsen COVID-19.
If you were on the fence about taking statins that were appropriately recommended to you I would strongly advise beginning them now.
Don’t, however, start statins based on these findings if you have no other indication for them.
As my patient’s case illustrates it is more important than ever during COVID-19 to continue to take appropriately prescribed statin drugs. If you think you are having statin-related side effects it is crucial to discuss the pros and cons of a trial off statins with your physician before stopping them.
Pleiotropically Yours,
-ACP
N.B. The nice graphics in this post come from an ACC presentation by Dr. Erin Michos which can be viewed here
21 thoughts on “Statins Are Your COVID-19 Friend: Keep Taking Them”
I’d like to hear more about “appropriately prescribed.” I’ve heard data from a relative, who has not taken recommended/prescribed statins, that they reduce risk for someone who has already had a heart event along with high cholesterol/LDL, but that there is not reduced risk absent the heart event.
Cori,
Those who have had cardiovascular events are considered secondary prevention and statins do work very well in this group.
Those without CV events, considered primary care, have to be risk stratified. Some are at higher risk than those with events and will definitely benefit from statins
Dr. P
Wow! I’m so, so glad to find a voice of reason on the internet. I have just been swinging from one side to the other – statins are the best thing since sliced bread or statins are the devil’s work. I will be following you. I am a 72 year old female – in the middle of Covid lockdown, 3 months ago, I had a STEMI – LAD 70% stenosed, mid RCA 95% stenosed – blood clot caused the heart attack. Two drug eluting stents inserted in the RCA and I was sent home with an armload of drugs – quite the adjustment for someone whose medicine cabinet previously only contained tea tree oil and apple cider vinegar. So far no side effects that disturb me. My health otherwise is excellent, no issues whatsoever. For the past ten years, my diet has been mostly vegetarian, mostly vegan – not exclusively (you could call me a skeptical vegetarian). Here are my questions: 1. I am committed to taking the statin prescribed -atorvastatin, but I would be interested in your thoughts on statins among the very elderly (assuming I get there). 2. I will also be taking blood thinners – Brilinta and aspirin for a year and would like your thoughts on whether the dual antiplatelet therapy is really necessary for a year – I find myself anxious about hemorrhagic stroke although I don’t believe I have reason to be. 3. I’ve also been prescribed Perindopril for blood pressure – I have no blood pressure issues 110/70 is normal for me but I was told it is prescribed not only for blood pressure but for survival rates, so my permanent medications would be statin, aspirin, and perindopril. How does that sound to you?
Angela,
Thanks for your kind comments on my blog. I’m happy your cardiology experience was a good one.
I cannot give medical advice but can comment in general on situations like yours.
Your questions are all good ones, by the way.
1. Statins are particularly helpful in secondary prevention like your case post infarct. They are going to be super important in you for the next 10 years at least. Depending on how we define “very elderly” their benefit is less and also likely less the farther away from your event and the longer they have had to stabilize your plaques. You should have a discussion with your cardiologist at least annually about whether you are on the right combination of meds in general but don’t stop any of them without such a discussion.
2. This question is continually being debated as it seems a new study is published monthlyl. Most recently it appears the dual therapy (DAPT for most is only needed for 6 months. Again, strictly follow your cardiologist advice but ask him at every visit , especially if you have any bleeding problems (or cost issues). Every individual is different and the duration of DAPT should be individualized.
3. Perindopril is an ACEI that I have never prescribed. This makes me wonder if you are not in the US. There is data that ACEIs lower event rates after an infarct. This is fairly old data, not sure if it applies in the rapid PCI with minimal cardiac damage era. Same thing applies to beta blockers.
My clinical approach to the post MI patient is to evaluate LV function by echo 3-6 months post infarct. If it is totally normal I feel the benefit of ACEI and BB is minimal and I discuss with the patient whether we should continue them. I haven’t carefully reviewed the data in this area for a while.
this is a good topic for a post on medications post infarct and I’ll look at potentially expanding this answer and posting it if time every permits.
Hello Dr. Pearson, Thank you for the very detailed and helpful response. You are correct, I am not in the US but in Canada. My cardiologist did agree to take me off the BB that was prescribed immediately post PCI, but seems attached to the ACEI, although has since agreed that I can take it every second day or half the daily dose. I’m sure we’ll renegotiate again after a few months since my chart indicates normal LV function. Yes, when you have time, I think many people would be interested in your thoughts on post infarct/post stent meds and other problems.
What about impact of statins on diabetic parameters of mentally bright, pre-diabetic, very low-risk cardiac individuals pushing 72 such as myself ?
I just want to say how gratifying it is to read a medical article that is so lucid and focused on helpful, accurate medical information. I’ve been a statin user for nearly 4 years after experiencing a stroke without an acute event. I have had no side effects as far as i know. I still suffer the effects of nerve damage caused by my stroke: principally numbness on my right side which causes various levels of difficulty in ambulation due to variable numbness in my right foot. My right hand and shoulder have limited functionality. All of these symptoms vary over time from severe to very mild. I recently resumed taking Neurontin in my quest to recover greater and more consistent functionality. If appropriate, I’d welcome any advice on what I can do to improve my condition.
https://www.bmj.com/content/368/bmj.m1182/rr-10
Herman,
You provided this reference without comment but I will assume that your intent was to support the recommendation of the author of this letter to the BMJ editor for patients on cholesterol lowering treatment to cease taking their treatment if infected with COVID-19.
The author is Uffe Rasnkov,the most prominent cholesterol skeptic in the world and hopefully evidence that has emerged as outlined in my post since this April 4, 2020 letter shows that his advice is unwise at best, reckless at worst.
He had a 99% blockage only 3 months after stopping his stations ? I call BS
Wally,
How many patients with coronary artery disease have you taken care of?
dr P
The statin denialist in some respects share a similar trait with physicians who over-prescribe statins, there is no appreciation of nuance.
The statin denialist usually focuses on a mechanism (much of which is steeped in pseudoscience and poor understanding) and then espouses that the drug is universally bad for everyone. There is no appreciation of specific sets of patients (those with familial history of early CV events, FH, Ca CT score reflecting plaquing…etc) that if caught early enough and treated with the optimal drug therapy can improve quantity and quality of life.
The statin denialist has no appreciation for the nuance that these studies only encompass a year or two of control of just one facet(LDL) of a very complicated disease that took years/decades to come to a head. They sometimes refer to statistics like absolute relative risks and say that % dif between cohorts and placebo are not that big. Their poor understanding of a very complicated disease process itself (ie it takes decades of exposure to LDL particles coupled with mitigating factors like metabolic syndrome, hypertension, fat distribution, complex immuno responses to endothelial lesions/damage and much more.) does not give them the perspective that the impact statins had in just one or two years on a disease that takes decades to impact health is astounding (in the right patient populations). For the right patients, statins are game changers, they are not meant for everyone with above normal LDL-C.
The overprescriber pushes statins on patients based on one biomarker LDL-C > guideline recommendation. Many times they don’t have any appreciation of advanced lipoprotein testing and have only a basic understanding of how the lipid transport system works. They often times look at statins as benign and are unwilling to acknowledge that in some patients they cause side effects like muscle pain.
They are on the flip side of the coin, they only acknowledge the positives and think the one size fits all approach is the safest approach to prevention. The nuance is lost, there is no CT Ca scoring done to see if their patents hypercholesterimia is causing cardiac arterial plaque forming, there is no advanced lipid testing to see if their could be a potentially more atherogenic lipoprotein like Lp(a) that potentially increase a patients risk for cardiac valve calcification or aortic stenosis, there is no investigation into LDL-P the actual number of lipoproteins (exposure) of a patient. They only see a number “bad cholesterol” is too high and we must get it down, without even understanding what the number means to their individual patient.
Christian,
Well said!
We MDs should be doing all we can to risk stratify for subclinical atherosclerosis and sudden cardiac death before adding meds
Dr p
Great information trust your judgement 100%..Linda LeBold.
Thanks again for great information
In addition, there is confusing information on Al Gore’s internet that statins may or may not increase dementia and Alzheimer’s.
Joe,
Al Gore and I thank you profusely for your observation.
Studies looking at observational data on statin usage find they are associated with reduced development of dementia. RCTs with statins do not find any evidence of increase cognitive problems or dementia.
However, I have seen patients like Al’s father who seem to clearly have worse mental function on some statins which improves off the statin. Like any potential side effect from a statin I advise a trial off the drug followed by a rechallenge with another statin if there is improvement off the drug.
I summarized the latest finding in 12/2019 here…..https://theskepticalcardiologist.com/2019/12/10/statins-and-memory-loss-the-latest-findings/
Perhaps you were drinking a mint julep and missed that post
Although I guess it’s not technically a statin, but any thoughts on Nexletol – can’t seem to find any information on this drug since it became available this year. I don’t see much advantage of this drug versus a generic statin.
We’ve seen some good results from Bempedoic Acid but I see it right now as a niche drug. I will try it patients who are statin intolerant or those who are high risk and need additional LDL lowering because not at goal with statin alone. In this respect it will be competing with other non statin treatments with proven efficacy including Zetia and the PCSK9 inhibitors.
So I am one of those “Statinistas” who thinks they are overused, in primary prevention. Whereas you have a story of a senior, I have a dueling-banjos story of another senior, my then-91-year-old father. He was and is not at high risk at all, but was on statins because it is a thing. He was also in what we thought was early stage-dementia. I got his doctor to take him off statins and the dementia went away. (It has subsequently come back, two years later — pretty inevitable on that side of my family.)
However, once I actually read your entire article and noticed that what you were saying was basically “COVID is one more thing to weigh in a cost-harm conversation,” well, we said exactly the same thing, though about baby aspirins.
We added four things. Here are two. First (this is less true now than when we said it in April), you are not getting out as much so your chances of an accident causing you to bleed out are noticeably lower. Second, a lot more people would (inappropriately but understandably) delay getting medical attention in the event of a suspected heart attack due to fear of COVID, meaning the average heart attack and hence the average avoided heart attack would be more severe. For the other two, you’ll just have to read the posting. https://www.quizzify.com/post/rethinking-the-baby-aspirin-in-the-time-of-covid
Al,
Your post reminds me of the Clash’s fantastic album Sandanista. The songs have maintained their vitality for 40 years.
However statinista is uncomfortably close to satanista and may be misconstrued. In fact, I would consider myself one who feels statins are overused in primary prevention and I’ve written frequently about deprescribing them in the right patients. I have recommended by 94 year old dad stop his statins (although he is post coronary stenting and statins plus aspirin have helped him avoid any subsequent coronary/cardiac issues for 3 decades).
Another factor (not sure if it is one of the residual two you mention) is that the frequency of Takotsubo cardiomyopathy appears much higher during Covid-19 than previous similar times.