Episode 218: Statin Therapy Fundamentals
What are statins?
Zohal: Statins are medications that lower cholesterol by inhibiting the enzyme HMG-CoA reductase, which prevents cholesterol synthesis in the liver. By doing so, statins decrease low-density lipoprotein cholesterol (LDL-C).
Why should we lower LDL?
Zohal: There are four main lipoproteins that transport fats in blood, including chylomicrons, VLDL, LDL, and HDL. This is where we get our “bad cholesterol” vs. “good cholesterol”. Of these, LDL is most associated with an increased risk in cardiovascular disease, while a higher HDL is associated with lower risk. Thus, reducing LDL subsequently reduces the risk of cardiovascular disease.
Arreaza: The lowest LDL I’ve seen was 25, and the highest HDL was 60. HDL doesn’t really have a strict upper limit, but most people fall between 40 and 60. Extremely high HDL—above 100—may not always be protective and can sometimes signal underlying issues.
Zohal: My HDL is 70! Statins are used for both primary prevention, meaning preventing cardiovascular disease before it occurs, and secondary prevention, meaning preventing disease progression in patients who already have cardiovascular disease.
History of statins.
Zohal: In the early 1900’s, researchers were studying the association between cholesterol and atherosclerosis, and at that time, they primarily used animal subjects. These studies were initially not taken seriously, because most believed cardiovascular disease in humans were simply due to aging and was not preventable.
It wasn’t until the middle of the century when researchers began observing that increased levels of LDL and decreased HDL was correlated with an increased rate of heart attacks. This finding prompted interest in determining the pathway of cholesterol synthesis in the human body.
Statins were first discovered in the 1970s when researchers identified compounds that inhibit a critical step in cholesterol synthesis. The first statin approved for clinical use was Lovastatin in 1987.
Since then, multiple statins have been developed, including Atorvastatin, Rosuvastatin, Simvastatin, and Pravastatin. Further clinical trials in the 1990s and 2000s showed that statins significantly reduce myocardial infarction, stroke, and cardiovascular mortality.
Why do Statins Matter in Primary Prevention
Zohal: Cardiovascular disease is the most common cause of death worldwide. As previously mentioned, elevated LDL cholesterol contributes to the development of atherosclerotic plaques within arteries, which can lead to heart attack and stroke. By lowering LDL cholesterol and stabilizing plaque formation, statins implemented in a timely manner significantly reduce the risk of atherosclerotic cardiovascular disease.
Arreaza: One of the things I love most about primary care is prevention. You’re working upstream, often quietly, humbly, helping people avoid disease before it starts. And the truth is—you rarely see the full impact of your actions. You don’t get a notification that says, “this patient didn’t have a heart attack because of you.” But every time you help someone control their blood pressure, quit smoking, improve their diet, or stay consistent with their medications, you’re shifting their tracks. You’re reducing risk in ways that may never be fully visible. That’s the paradox and the beauty of it: in primary care, your highest victories are often events that never happen.
Who Should Receive Statins for Primary Prevention?
Zohal: Recommendations slightly differ depending on who you ask. We look to the U.S. Preventive Services Task Force, the American College of Cardiology, and the American Heart Association for their recommendations regarding statins for primary prevention.
USPSTF on statins.
The U.S. Preventive Services Task Force (or USPSTF for short) is an organization that works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life. They recommend statins for the primary prevention of cardiovascular disease in:
- Adults 40–75 years old
- With one or more cardiovascular risk factors such as dyslipidemia, diabetes, hypertension, or smoking
- AND a 10-year cardiovascular risk of 10% or greater
Their recommendations are graded A, B, C, D, and I, depending on the strength of evidence and this is a Grade B recommendation.
Arreaza: So, you have to meet all the criteria to receive a statin, according to USPSTF: 40-75, one CV risk factor and a high 10-y ASCVD score, by the way, the ASCVD risk calculator was introduced in 2013 by AHA/ACC. It is available online for free and many EHRs have integrated this tool into their software. For example, if you use EPIC, you can type .ascvd and get a score automatically. What about patients with a cardiovascular risk less than 10%?
Zohal: For patients with a 7.5–10% risk, some may offer statin therapy on a case-by-case basis as this is a Grade C recommendation. But I’ll get more into this later.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
_____________________
References:
- Grundy SM, et.al, Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082-e1143. doi: 10.1161/CIR.0000000000000625. Epub 2018 Nov 10. Erratum in: Circulation. 2019 Jun 18;139(25):e1182-e1186. doi: 10.1161/CIR.0000000000000698. Erratum in: Circulation. 2023 Aug 15;148(7):e5. doi: 10.1161/CIR.0000000000001172. PMID: 30586774; PMCID: PMC7403606. https://pubmed.ncbi.nlm.nih.gov/30586774/
- U.S. Preventive Services Task Force. (2022, August 23). Statin use for the primary prevention of cardiovascular disease in adults: Preventive medication.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medicatio
- American College of Cardiology ASCVD Risk Estimator: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
- Guideline Central. (2026, March). ACC/AHA dyslipidemia guideline spotlight (March 2026).
https://www.guidelinecentral.com/insights/mar-2026-accaha-dyslipidemia-guideline-spotlight/
- Endo A. A historical perspective on the discovery of statins. Proc Jpn Acad Ser B Phys Biol Sci. 2010;86(5):484-93. doi: 10.2183/pjab.86.484. PMID: 20467214; PMCID: PMC3108295. https://pubmed.ncbi.nlm.nih.gov/20467214/
- Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.
