Why you should not give up cholesterol-lowering drugs or statins after a heart attack and have them for a lifetime

Often, people who have had a heart attack or even stenting mistakenly feel that they do not need cholesterol-lowering drugs anymore. They assume that since their blockage has been addressed through surgical intervention or medication, and they have been prescribed lifestyle modification with heart drugs, chances of their cholesterol levels rising are low. And once they are confident of their body and recovery, misinterpreting their drug-induced limiting effect on cholesterol levels as their natural body function, they often discontinue cholesterol-lowering drugs or statins on their own. And the cholesterol climbs right back.

Some years ago, a study of nearly 60,000 people, age 66 and older, which was published in JAMA Cardiology, found how often people stop taking statins after a heart attack. Within two years of having a heart attack, nearly one in five people had stopped taking statins. And nearly two in five did not take the medicine as prescribed. They either took a lower dose or took it less frequently.

People who have had a heart attack or stroke need to take cholesterol-lowering drugs or statins life-long post-event to reduce the risk of them having another event. So, what do statins do? They work by blocking a substance your body needs to make cholesterol. Apart from lowering cholesterol, they stabilise the plaques on blood vessel walls and reduce the risk of blood clots. Most people associate clotting with the heart. But it can happen in any artery of the cardiovascular system, leading to brain strokes and resultant paralysis. Blockages in kidney arteries could lead to kidney problems and those in the limb arteries could even result in amputation. As the plaque closes limb arteries, fresh blood cannot pass to nourish organs and other tissues below the blockage. This causes damage mostly to the toes and feet and is known as Peripheral Artery Disease (PAD) and in serious cases, patients end up losing their limbs.

Cholesterol-reducing drugs or statins are preventive on two counts. First is for primary reasons, where they are prescribed for high-risk patients whose blood markers are not good and are genetically predisposed to heart disease. The secondary reason is the onset of the heart attack itself where it helps prevent repeat episodes in the future.

After a heart attack, a statin has to be taken for as long as the risk exists, which is life-long. Even without an episode, it is prescribed for people at both low and high risk. You are at low risk when you have a history of atherosclerosis and your LDL requirement is below 70 mg/dL. High risk is when you are young, say 35, have had a heart episode and have a family history. In such a situation your LDL should be below 50 mg/dL, a level which is difficult to maintain without statins.

There are new drugs to reduce LDL cholesterol other than statins. These are PCSK9 inhibitors and are available as injection Repatha. Now, 140 mg injection is given subcutaneously twice a month to keep LDL cholesterol in check. Each injection costs Rs 15,000, so you have to set Rs 30,000 aside. Statins work out cheaper. Another drug is Ezetamide in tablet form, but it is less useful than statins or Repatha.

If statins are causing side-effects you cannot handle, like digestion issues, muscle pain, sleep issues, then ask your cardiologist to tweak the dose in a way that you do not feel any side effects and your body can adjust with the dosage. Some people decide on their own that since they feel better, they do not need the same dosage as before. But they must remember that their ultimate goal is not lesser medication but lesser chances of having another stent, bypass or a heart attack.