Few medicines have sparked as much debate as statins. Cardiologists often describe them as life-saving, while some patients remain wary of side effects or uneasy about taking a daily pill.
Statins sit at the intersection of medical treatment and everyday lifestyle because high cholesterol is strongly influenced by factors such as diet, physical activity, weight and smoking. Although statins are prescribed based on clinical evidence, their use often prompts questions about whether cardiovascular risk should be reduced primarily through medication, lifestyle change, or a combination of both.
Statins are a group of drugs that block an enzyme called HMG-CoA reductase. This enzyme plays a central role in the liver’s production of cholesterol. Cholesterol is a fatty substance the body needs to build cell membranes, produce hormones, make vitamin D and generate bile, which helps digest fats.
Cholesterol travels through the bloodstream attached to proteins, forming particles known as lipoproteins. The most familiar are low density lipoprotein (LDL) and high density lipoprotein (HDL).
LDL is often labelled “bad cholesterol” because high levels can lead to fatty build-ups inside arteries, while HDL helps transport excess cholesterol back to the liver. Another important blood fat is triglycerides, which, when elevated, also increase cardiovascular risk.
Cholesterol itself is not harmful. Problems arise when LDL and triglyceride levels remain too high for too long. This can lead to atherosclerosis, a condition in which fatty deposits narrow and stiffen arteries, increasing the risk of heart attacks and strokes. By lowering LDL cholesterol and triglycerides, statins reduce the likelihood of these deposits forming.
Large clinical trials have consistently shown statins to be effective. A major review found that statins significantly reduce the risk of heart attacks and stroke.
The size of the benefit depends on a person’s underlying cardiovascular risk and how much their LDL cholesterol is lowered. Reflecting this evidence, national guidelines recommend statins for primary prevention in people at higher risk who have not yet had cardiovascular disease, and secondary prevention for those with established disease.
Given this strong evidence, why do statins still generate so much hesitation?
Like all medicines, statins have side effects. Common ones include headache, digestive upset and dizziness. More serious but uncommon or rare effects include liver inflammation and muscle problems.
One such condition is myopathy, meaning muscle pain or weakness with raised levels of creatine kinase, an enzyme released when muscle tissue is damaged. In very rare cases, severe muscle breakdown known as rhabdomyolysis can occur.
Large datasets show that most people tolerate statins well. When patients report muscle symptoms while taking statins, there is less than a 10% chance that the statin is actually the cause. Rhabdomyolysis is extremely rare, affecting only a few people per million users. The risk increases at very high doses or when statins are taken alongside medicines that interfere with how they are broken down.
Statins can also cause a small rise in blood glucose, mainly affecting people with prediabetes or diabetes. However, because statins substantially reduce heart attack risk in these groups, the overall benefit outweighs this modest increase. Most side effects are reversible once treatment is stopped, whereas damage from heart attacks or strokes can be permanent.
Drug interactions are another concern. Statins such as simvastatin and atorvastatin are broken down in the liver by enzymes known as CYP enzymes, particularly CYP3A4. When other medicines block these enzymes, statin levels in the blood can rise, increasing the risk of muscle-related side effects.
Important interactions include antifungal medications such as ketoconazole, certain antibiotics like erythromycin, immunosuppressants such as ciclosporin, and some heart drugs including amiodarone and diltiazem.
Even grapefruit can interfere with statin metabolism. It contains chemicals called furanocoumarins, which block CYP3A4 enzymes in the gut, allowing more statin to enter the bloodstream. Not all statins are affected to the same extent, so switching to a different statin could reduce this risk.
While statins are effective, they are not the only tool for managing cholesterol. Lifestyle measures play a central role and are recommended alongside medication. Obesity is a major cardiovascular risk factor.
A review found that combining diet and exercise reduced body weight, improved cholesterol levels and lowered cardiometabolic risk: it reduces factors linked to heart disease and type 2 diabetes.
Dietary changes are particularly important. National guidelines recommend reducing saturated fat intake to help lower LDL cholesterol. Saturated fats are commonly found in butter, fatty meats and processed foods.
Replacing them with unsaturated fats, such as those found in olive oil, nuts and seeds, can improve cholesterol levels. Shifting towards plant-based proteins like beans, lentils and soy may also reduce reliance on red and processed meats.
Fibre intake matters too. Research shows that higher fibre consumption is associated with better cholesterol levels and lower heart disease risk.
A large 2019 review found that people with high fibre intake had a 15 to 30% lower risk of dying from heart disease or developing coronary heart disease. Whole grains, fruits and vegetables provide fibre alongside vitamins and antioxidants that support heart health.
Regular physical activity raises HDL cholesterol and lowers triglycerides. Current guidelines recommend 150 minutes of moderate-intensity exercise per week, but even smaller amounts offer meaningful benefits.
The choice between statins and lifestyle change is not an either-or decision. For people at high risk, including those with previous heart attacks, inherited cholesterol disorders or multiple risk factors, statins are often essential.
For others with mildly raised cholesterol, lifestyle changes may delay or prevent the need for medication. Healthy total cholesterol levels are usually below 5 mmol/L, but targets vary depending on individual risk.
Ultimately, treatment decisions should be personalised, balancing cardiovascular risk, the proven benefits of statins, potential side effects and what lifestyle change is realistically achievable.
Statins have transformed cardiovascular care and saved millions of lives. Yet they remain controversial. Addressing poor diet, physical inactivity and obesity remains central to reducing the burden of heart disease in the long term.
Dipa Kamdar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
