Are Cholesterol Drugs As Beneficial As We Are Told?

An article published in BusinessWeek (January 28, 2008) raised pointed questions about the widespread use of statin drugs for lowering cholesterol. Titled “Do Cholesterol Drugs Do Any Good?”, the article examined how statin benefits are often presented and how those benefits translate into real-world outcomes.

One statin advertisement cited a 36% reduction in heart attacks among patients with multiple risk factors. However, the fine print revealed that 3% of patients in the placebo group experienced a heart attack compared to 2% in the statin-treated group. In absolute terms, this represents one fewer heart attack per 100 people treated — a number needed to treat (NNT) of 100. The article noted that the benefit of statins is greatest in people with established cardiovascular disease and far less clear in those without prior heart attack or active disease.

Statins work by inhibiting the enzyme HMG-CoA reductase, which blocks the production of mevalonate. While this reduces cholesterol synthesis, mevalonate is also required for the production of other important compounds, including coenzyme Q10 (CoQ10). Reduced CoQ10 levels have been associated with muscle pain, exercise intolerance, and, in rare cases, serious muscle injury such as rhabdomyolysis. The FDA has also issued warnings regarding liver injury associated with statin use. Severe adverse effects occur in a small percentage of users, but are clinically significant when they occur.

The heart is particularly rich in CoQ10, and lower levels have been observed in people with congestive heart failure. An article in The Lancet (1998; 352 Suppl 1: 39–41) noted a marked increase in the prevalence of heart failure over recent decades. While many factors contribute to this trend, the potential metabolic consequences of long-term cholesterol-lowering therapy have been the subject of ongoing discussion.

The BusinessWeek article did not address CoQ10 depletion, but it did highlight the importance of distinguishing relative risk reductions from absolute benefit when evaluating statin therapy.