How Do Statins Lower Cholesterol? with Tamanna Singh, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Have you ever taken apart the drainpipe beneath your sink and looked inside? If so, you know it's often not a pretty sight. Things can get pretty gunked up in there. It's the same story with arteries carrying blood through your body. These pipes can get clogged with a buildup of plaque, which can increase your risk of a heart attack or stroke over time. Medications known as statins are often used to help limit plaque and keep those arteries open. Today, we're going to talk to cardiologist Tamanna Singh to learn how statins work and how effective they can be. Dr. Singh is one of the many experts at Cleveland Clinic who visit our podcast to chat about life-saving advances in medical care. So with that, let's get some information flowing about statins and why they are one of the most prescribed medications in the world.

Welcome back to the podcast, Dr. Singh. We always appreciate you stopping by to chat.

Dr. Tamanna Singh:

Thanks so much for having me. It's always a blast.

John Horton:

We love having you. And you're here with us today to talk about statins. And I've got to be honest with you, I had no idea how much they were used until I got a prescription for them and mentioned it to a few friends. It turns out, almost all of my buddies are already on them.

Dr. Tamanna Singh:

Yeah, I mean, they're incredibly common. I think the last statistic I saw was at about 39 million adult Americans are actually on statins, with the largest demographic actually being that 40-plus age range. And that really parallels what we expect when we start to think about the increase in cardiovascular risk, the consequences of perhaps the sedentary, high-stress, high-fat lifestyle. All of those things start to kind of hit us, and we feel them once we get out of our youthful ages and decades of life into the 40s and the 50s.

John Horton:

Yeah, I'm definitely a little bit out of the youthful stage.

Dr. Tamanna Singh:

Never.

John Horton:

Yeah, a couple years past that now. So obviously, statins are all over the place and people are using them. How do they work their magic?

Dr. Tamanna Singh:

OK, we're going to get a little nitty-gritty here. So in terms of where cholesterol comes from, I think that's a nice place to start. So most of our cholesterol, about 75% of it actually, is produced by our bodies, and then the remaining 25% comes from our diet, so what we eat. And our liver actually plays an incredible role in the production of cholesterol. And so what we would want to do, if we want to lower the amount of cholesterol we're actually producing, we'd actually want to do two things. One, a medication that inhibits that production would be helpful, and then a medication that also simultaneously helps to increase the uptake of bad cholesterol from the blood would be a solid way to reduce our risk. So that medication is a statin, and statins are more specifically HMG-CoA reductase inhibitors. That is a mouthful.

John Horton:

That is a mouthful!

Dr. Tamanna Singh:

And the HMG-CoA reductase enzyme is what plays the very important role of cholesterol production in the liver. So you can imagine if we block that role, we'll really reduce our cholesterol production.

John Horton:

Now, you mentioned bad cholesterol, LDL cholesterol, which I always know, the L is for “lousy.” Statins really kind of particularly target that, correct?

Dr. Tamanna Singh:

Oh, yeah. So one of their other impacts is they actually increase the placement or the generation of LDL receptors on the liver. So LDL, the bad cholesterol that's floating around in your blood, attaches to these receptors. The more receptors you have, the more you can pull into your liver, which is also responsible for metabolizing and breaking down those particles. So if you take up more, you'll break down more LDL and eliminate them. So that's really-

John Horton:

…so it's scrubbing your system a little bit.

Dr. Tamanna Singh:

…yeah, I guess, it's cleaning up the blood. Yeah, it's kind of like a very specific vacuum cleaner. You could probably think of it that way.

John Horton:

You have all this going on. And we talk about plaque, and I think everyone's familiar with that term. What exactly is it when you're talking about this stuff that's kind of getting stuck to the walls of your arteries?

Dr. Tamanna Singh:

Yeah. So plaque is actually made up of several different materials, one of which is this fatty core or lipid-rich cholesterol-rich core. So if you have a lot of excess cholesterol in your blood, it's got to go somewhere. And oftentimes, what it does is, it latches onto the lining of your blood vessels. And these fatty-rich plaques, which is how we describe them, or athero or arteriosclerosis, is very vulnerable. It's — how I describe to my patients — soft, squishy, sticky plaque. If any of it breaks off — it's very easy to break off — it can really disrupt blood flow in that vessel. It's very attracted to clotting factors and molecules that can lead to an abrupt cessation of blood flow. It's kind of like Cleveland roads. Cleveland roads are riddled with potholes. Those potholes that get filled with really crappy asphalt are really prone to coming out as potholes again. So I kind of equate, unfortunately, the lining of cholesterol-riddled blood vessels to Cleveland roads, but it essence-

John Horton:

…I love that explanation.

Dr. Tamanna Singh:

…but yeah, so in essence, what I'm saying is if you have very disruptive, inflammatory-lipid-rich cholesterol plaque, your risk of having a heart attack or a stroke … if that cholesterol plaque is in your brain and those brain vessels are markedly elevated … and so statins can help stabilize these plaques.

What does stabilization really mean? It can essentially kind of leach out that cholesterol-rich core. It helps to make that cholesterol plaque very stable, less inflammatory. And it's kind of like the best way to create a smooth, well-paved, tolerant road in the Cleveland City area.

John Horton:

Yeah. When we look at this plaque, I know we all think of it as it builds up on those artery walls, and it keeps getting narrow, and then it inhibits the blood flow. And obviously, that's a problem because you want max flow going through those arteries. But I also read where it hardens the arteries and it kind of increases the chance of a rupture. How does it harden them? Is it just that the arteries aren't as flexible?

Dr. Tamanna Singh:

Yeah, so vessels inherently … when you're born with them or if you're very active, you eat very well, you have good genes from a cardiovascular perspective, those vessels are incredibly pliable, incredibly flexible. They're like Twizzlers™, very pliable, very flexible, very clean inside. And what happens is when you start to accumulate some of this cholesterol crud, cholesterol plaque, all of that kind of makes that Twizzler less bendy, right? It gets a little stiffer, and you're also disrupting the health of that inside lining of the vessel. Once you do that, once that lining is unhealthy, it again leads to this inflammatory, stiff, less pliable vasculature. And so the more rigid a vessel is, the less likely it is to dilate appropriately when you're trying to maximize oxygen-rich blood flow through that vessel.

So when we think about situations where we want to maximize oxygen-rich flow — exercise, that's probably the easiest thing. Or at times of stress, we want our vessels to dilate, allow for a lot of oxygen-rich blood to get to where it needs, whether it be our heart and our muscles without issue. If you have a very high cholesterol-rich diet or bad genes or a sedentary lifestyle, that cholesterol plaque inhibits the ability for that vessel to dilate to get bigger, limits oxygen delivery to the area that needs it. And when it comes to the heart, your heart’s and muscle, if it doesn't get enough oxygen, it's going to start to hurt. And that's what can manifest that "chest pain" that people often describe.

John Horton:

And yeah, … that's what … leads to, you could end up with a heart attack, with stroke, I mean, big things that we all know are not good and really can be life-threatening.

Dr. Tamanna Singh:

Yeah, and there's two ways people can get heart attacks. I think the one most common way we see on TV or even in real life is someone clutches their heart and it's like, "Oh my God, I'm having a heart attack. There's an elephant on my chest," or they just drop. That's what we call acute plaque rupture. It's that situation where some of that unstable, soft, squishy cholesterol plaque breaks off, gets into the lumen, that space of the vessel, attracts all of these particles and molecules that form plugs and immediately impedes blood flow to the heart. That's an abrupt acute coronary event.

The other common way that takes a little more time is the sedentary lifestyle, the genes and the diet. So over decades of time, as you have excess cholesterol, it's going to accumulate in the lining of those vessels, and as you described earlier, encroach on the space. So that really wide pipe becomes a little bit smaller in diameter, smaller, smaller, smaller. And then at some point, it's so small and so stiff that when you're really trying to maximize blood flow through that vessel, you just can't get it there efficiently. And so that leads to this onset of symptoms over time, which can lead to heart attacks.

John Horton:

Well, let's talk about that, because as you mentioned, a lot of people end up … maybe they start taking statins when they're no longer youthful, past that youthful stage, as you kind of phrased it. If you start taking statins, can it actually reverse that plaque buildup that you might have? Or does it just kind of stop it from getting worse?

Dr. Tamanna Singh:

Yeah, no, that's an excellent question. It's one that we've actually studied here at the clinic with our lipid specialist and our lipidologist. So we, oftentimes, will inform patients that if we can get their LDL, their bad cholesterol, low enough — what is low enough? So typically, in our non-diabetic population below 70, and people with aggressively high cholesterol or diabetes or pre-diabetes, much lower, less than 55, if we can get it below these thresholds, we can see plaque regression. And I guess the best visualization of that is really getting rid of that fatty lipid cholesterol-rich core and leading to plaque stabilization or even some shrinkage of the plaque.

Now, I think one number we've quoted here at the clinic is that you could potentially see plaque regression of up to 24%, but I think most of us cardiologists say, "Hey, the lower the LDL, the better.” Really, so that if there is any room for plaque regression, we can actually see it.

John Horton:

I have to tell you, Dr. Singh, and you know, because I don't just talk to you on the podcast, I also go and see you for myself, I ended up on a statin and it took my LDL down almost in half, and it happened so quickly. It was, I think, over the course of a little more than three months. I went and looked it up and I couldn't believe how it dropped. And I went from somebody who was a little over where you really wanted to be with total cholesterol and way over where you wanted to be with LDL to being just in a great range.

Dr. Tamanna Singh:

Yeah, I mean, statins are incredibly effective. They do come in a wide range of colors from least potent to most potent. Most of us cardiologists, depending upon our patient and what their needs are, typically favor more moderate to high-potency statins because we want the biggest bang for our buck. And I personally like to be quite efficient in my practice with my patients. I don't need to linger and slowly wait for the LDL to draw down to less than 70. I want it to be big, I want it to be impactful, and certainly, I want it to be well-tolerated. So we can see in some individuals upward of 38 to 40% reduction; sometimes, a little more, sometimes, a little less, again, depending upon the statin's potency. But we usually will see an impact within about two to three months.

John Horton:

Wow. I mean, that's incredible. And I know I was amazed, and you really feel good when you get those results back. I mean, we often talk about how high cholesterol, it's a silent killer and it's easy to wave off because you feel great and everything's good and you don't notice anything. But inside, those arteries don't lie. And if they close up and have problems, you're going to have problems.

Dr. Tamanna Singh:

Oh, certainly. I mean, you will not feel those problems until those vessels are so small that they're encroaching on your ability to do the activities you want to do, or if you do, unfortunately, have an acute heart attack.

So this is where we say, really, for any age, even our pediatric population to our post-pubescent individuals, our young adults and certainly demographics beyond, lean into learning and knowing your family history, understanding what your cardiovascular risk is. It's always better to be on zero to one medications versus five down the line after a catastrophic event. I have some individuals who are 18, 19, 20 years old who have taken control and empowered themselves to learn more about cardiac risk. Even my athletes who have high cholesterol or other cardiovascular risk factors have leaned into being really aggressive about LDL reduction.

Now, we do have some control over how much reduction we can see or how much medication we may need for the reduction we're looking for. And what I mean by that is if we take control of our nutrition, if we have intention behind our movement, that may be a way that we can maybe not need as much of a medication as we initially need it.

Now, genetics is something that's unfortunately out of our control, and everybody has different genes — some people are just at higher risk versus not. But if you utilize a statin in the way we've described, increasing LDL uptake, decreasing cholesterol production and enhancing plaque stabilization, your cardiovascular risk over time will be markedly low. There's a reason why we joke and say statins should just be in the water, particularly within our American culture, because of the way most of us eat and live, because that's probably one of the best ways to reduce the risk of heart attack and stroke.

John Horton:

Well, I'm a pretty stubborn patient, and I know I'm not one who gravitates toward that. And after taking them and seeing what they did, I'm convinced that they've probably saved my life. I would've been one of those guys they found on the side of a park trail dead of a heart attack at some point. So I'm a big believer in them.

So when we talk about statins, what are some of the familiar names that people might hear as far as the medications that are out there?

Dr. Tamanna Singh:

Yeah, I would say the most common ones we use are certainly those higher-potency statins. So common names are like Lipitor®, Crestor® — or their generics are atorvastatin and rosuvastatin. Those are probably the most common ones we use. Older statins … I think one of the oldest ones is simvastatin or Zocor®. Many of us don't use that as much just because of the side effect profile. We find with the newer statins, people tend to get less side effects. And then, less potent statins that maybe some people have heard of, but most of us may not necessarily use in the average population, would be fluvastatin, lovastatin, pitavastatin, pravastatin. So anything that ends in “statin” is like-

John Horton:

…yeah. Hence the name.

Dr. Tamanna Singh:

…yeah.

John Horton:

So all these medications, I mean, they all kind of do the same thing, but do they just kind of do it in slightly different ways?

Dr. Tamanna Singh:

So there are two different classes of statins. Some can easily enter cells. So those are lipophilic statins. And then others are more liver selective, so those are hydrophilic statins. The common ones I described like Crestor or rosuvastatin, is hydrophilic; atorvastatin is lipophilic. So that's probably the difference among the statins. But otherwise, they all tend to work very similarly in those three ways that we described.

John Horton:

Now, you had mentioned the potential for side effects, and that's with any medication. What sort of issues might folks experience with statins?

Dr. Tamanna Singh:

I think the most common one, maybe the one that shows up top at the Google search, is muscle aches and pains or statin-induced myalgias. I think, especially my athletes are most concerned about statins impacting their performance, and I think that's where a lot of education can be done. There's a series of randomized control trials that stated that really only about 1.5 to 10% of individuals develop these statin-induced myalgias or myopathies. It's a very small number. There's some studies to suggest that perhaps taking coenzyme Q1910 or CoQ10 and vitamin D may help limit or eliminate some of these statin-induced muscle aches and pains. But that data is really controversial. So it's not something that we've included in our guidelines, but I've had some patients who've had a lot of success and others who were like, "CoQ10 is not made for me." That's probably the most common one I hear about.

Another one that tends to make people uncomfortable is this concern that statins cause diabetes. And the thing I say is, "If statins caused diabetes, with diabetes being a known cardiovascular risk factor, it would've been pulled off the market a long time ago." The actual impact on causing an increase in blood sugar levels or even provoking Type 2 diabetes is incredibly, incredibly low. I think there was a study or an analysis of about 20, 23 randomized controlled trials that actually showed that the annual risk was only about 1.3% in individuals on statins versus 1.2% on placebo. So that's very, very, very small.

John Horton:

Yeah.

Dr. Tamanna Singh:

Most often, individuals who are on statins, unfortunately, have poor blood sugar profiles or are pre-diabetic or are leaning toward diabetes anyway, and so we want to make sure that we reduce their cardiovascular risk from both ends. Several, maybe less common, but certainly conversational pieces at visits with me, with respect to side effects, I've had individuals have diarrhea. I've had a number, I don't want to say a number, but few patients, endorsed maybe some brain fog or some cognitive cloudiness, maybe some headaches, maybe some drowsiness. But I would say the number of individuals in my practice over the number of years I've been here that have endorsed those side effects, I could likely count on maybe one hand.

John Horton:

Yeah. And I take it that's the sort of thing with all these options we have and the different statins. Sometimes, just, I take it, switching from one to the other might kind of alleviate those.

Dr. Tamanna Singh:

It's possible. Certainly, switching from a high-potency statin to a lower-potency statin may be helpful. Some of our lower-potency statins certainly have better side effect profiles, but at the end of the day, the question is Why are we on a statin and how much do we need to get from the statin? At this point in time, we have so many other medications that we can utilize to help with cholesterol reduction. They may not have the same benefits like plaque stabilization and whatnot, but perhaps we can use a tiny dose of a statin with another cholesterol medication to get that reduction, as well as plaque stabilization. So there's many different kinds of recipes we can utilize to ensure that we're really getting the best bang for our buck with cardiovascular risk reduction.

John Horton:

Now, while statins, as we've talked about, certainly take care of business with lowering the cholesterol and especially getting rid of that bad cholesterol, I'm guessing they work best if you're also taking other steps to address those sorts of issues. So what other things can people do to reduce their cholesterol and help those statins be even more effective?

Dr. Tamanna Singh:

Yeah, I think it's a special individual who says, "Hey, I'm going to take my statin and eat my steak, too." Right? So we certainly want to make sure that we're doing all that we can to get our cardiovascular risk lower. And to be fair, there are individuals out there who may not have yet developed the motivation or have bought into intentional movement and intentional nutrition, and those individuals may just need higher intensity statin to get the LDL reduction that we're looking for. But I really do try to empower individuals to control the controllables, and that's what you put in your mouth and how you move your body. And if you're able to control both, you can certainly reduce your risk and reduce the dose you need.

So what do I mean by that? And we look at our diet, the thing that we want to minimize, in some cases really, eliminate saturated fat. Saturated fat is found in animal products. So we're thinking, animal meats, dairy, cheese, eggs. And then in the plant-based world, coconut and palm oil are the two oils that have saturated fat. Saturated fat is what contributes to that cholesterol-rich core and plaque. And it certainly-

John Horton:

…that's the gunk that ends up in there.

Dr. Tamanna Singh:

…yeah, the gunk, as well as all that bad cholesterol floating around in your blood vessels.

So if we can reduce that in itself, if you have less LDL floating around, you may not need as high of a dose of a statin to get rid of all that LDL, right? The less you eat, perhaps the less medication you need. But saturated fat is really the main player when it comes to how we can optimize our nutrition. Certainly, lean into healthy fruits, vegetables, leafy greens, whole grains, unsaturated fats, which do not contribute to cholesterol accumulation, that's your nuts and seeds and avocados, your olive oils, your avocado oils and whatnot. All of those are wonderful foods, helpful to increase your good cholesterol, your HDL, which you want high, right, H are “high,” and those can also help to control your triglycerides. Statins can reduce your triglycerides in themselves, but your diet can certainly help with your entire lipid profile.

And then exercise. I mean, exercise reduces cholesterol as well. So your heart really doesn't care what you do, but if you're active most of the days, and that doesn't necessarily mean having an active lifestyle, exercise is intentional physical activity, add that intention and movement most days of the week, and you can also break down your cholesterol.

John Horton:

Yeah, it is amazing what a healthy diet and regular exercise can do. So it seems to solve a lot of our problems.

Dr. Tamanna Singh:

Yeah.

John Horton:

Now, if you go see your doctor and all of a sudden, discussion comes up like, "Hey, I think you need to start taking a statin." It can be pretty jarring to hear that. I know my first reaction was not, "Woohoo. I'm now joining the club!" For somebody kind of experiencing that and having that initial reaction, what advice do you give as to how they should handle it?

Dr. Tamanna Singh:

Yeah, I think the first questions I always like to ask are, "What are your goals? What are your health goals? What are your performance or your lifestyle goals?" Because I think once individuals actually sit down and think about that, it helps to put everything else into context, right? If your goal is to live a healthy, mobile, high-functioning quality of life for as long as possible, and the one thing that we can help to control to make that happen is your cholesterol, why not? Why not lean into taking a medication that can help you do what you're doing for as long as possible? As I kind of alluded to earlier, I really try to lean into, "Hey, now's the time for prevention. Now's the time to prevent you from being that person who collapses."

If this is just one medication that we're talking about, one is way better than four or five down the line. Or unfortunately, having the consequences, the neurological consequences from stroke or the cardiovascular consequences from a heart attack. So I think if you can know your patient as a provider and then, from the patient perspective, really understand how you want to live, and that's kind of an existential question, but also something I think we should all be thinking about as we age and live our lives in this world, it becomes a much easier decision to make. And it may be motivating, right?

If you're someone who's like, "I don't want to be on medication." You're going to be the person that I say, "Hey, let's use this medication for now. Let's use it at this dose.” You come back in three months, tell me what you've done to change your diet, how you've incorporated more activity into your lifestyle. If we see a really significant reduction with medication and lifestyle, we can certainly play around with how much statin we need. Right? It's just a balance of, again, what can we control, what do we need a little bit of help with?

John Horton:

Yeah. And it is amazing. I have to say, I know for me, the thing that really drove it home was getting that first blood test after I started taking it and just seeing the results. And I remember being nervous going in, because it's like, "Is this really going to do anything?" And I was blown away at the difference it made. And like I said, I feel like it's going to extend my life. So I want to thank you for that.

Dr. Tamanna Singh:

I mean, you did the hard work. You also made a lot of dietary changes. You've stayed active, so you really leaned into the power of your lifestyle and your lifestyle choices, which makes it, really, a lot more fun and gratifying for me as a provider, right? My job is not to just dole out medications. My job is, hopefully, and not really my job, my privilege, is to help people feel motivated and empowered to do the best with what they have. And if I can help out in any way, I'm happy to do so.

John Horton:

Well, I'm glad you are, and I'm happy I'm going to have time with my family, my grandkids and all that stuff. Plus, I get to keep coming in here and having these fascinating conversations with doctors like you. So Dr. Singh, once again, thank you so much for coming in and, just, I love talking with you.

Dr. Tamanna Singh:

Always a joy, my friend. Keep doing what you're doing. You're doing great.

John Horton:

Statins are a highly effective medication for lowering your cholesterol and limiting the buildup of life-threatening plaque on the walls of your arteries. They work, and I can tell you that from personal experience.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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