Monday, February 1, 2016

Athletes and Statins

by Larry Creswell, M.D.

In a previous article, I wrote about the general issue of serum cholesterol and lipid levels and I’ve always encouraged athletes to “know their numbers.” I'd like to extend that conversation and talk about the most common scenario I hear about: the athlete who has a high low-density lipoprotein (LDL) level and who is encouraged to take a statin medication for treatment.

By way of a short review, the serum lipids include the cholesterol, the “bad” LDL, the “good” high-density lipoprotein (HDL), and the triglycerides. The desirable level for the LDL is less than 100 mg/dL.

The cornerstone for therapy for an increased LDL is a combination of an appropriate diet, attaining and maintaining an appropriate body weight, and increased physical activity. If those approaches alone are not successful in a reasonable time period, a statin medication is often recommended.

The statin medications are a collection of drugs that lower serum cholesterol levels by inhibiting the production of cholesterol in the liver. They block an important enzyme called HMG-CoA reductase and are therefore known collectively as HMG-CoA reductase inhibitors. These drugs are some of the most commonly prescribed medications in the United States and you will recognize many of the trade names from the ubiquitous print and television advertising: Crestor, Pravachol, Lipitor, Zocor. By some estimates, Americans have now spent more than $50 billion total on these medications.

The statin medications are very effective in lowering the serum LDL level, but they come with occasional, unwanted side effects. The most common problems are with elevation of liver enzymes (which must be checked when starting therapy) and muscle pain or cramps. Less common problems can include severe muscle breakdown called rhabdomyolysis, diabetes and cognitive problems.

And that brings us back to our athlete scenario.

The value of a statin medication depends upon the athlete’s risk for having a cardiovascular event such as a myocardial infarction (MI) sometime in the future. There are several ways to quantify that risk. One online tool provided by the American Heart Association is called the Heart Attack Risk Calculator. Another potentially useful tool is the test we call the coronary artery calcium (CAC) scan. Each can provide an estimate of the future risk of an untoward event such as an MI. The greater that risk, the more valuable the statin medications can be.

For individuals who have already suffered an event such as MI or stroke, and are found to have an elevated LDL, the evidence is convincing that a statin medication reduces the future risk of MI and stroke substantially. This is called secondary prevention because we’re trying to prevent a second event. The use of statin medications in this situation is not controversial.

When individuals have no pre-existing cardiovascular disease and no history of events such as MI or stroke, there is controversy about the role of statin medications. Here, we’re considering these medications for primary prevention, to prevent the first untoward cardiovascular event. Many athletes with an elevated LDL level by virtue of a healthy lifestyle fit into this situation.

  • The pros of statin therapy for primary prevention: Large scale trials have shown statin medications to be associated with a significant reduction in MI and stroke for both men and women. This effect is most pronounced for individuals at highest cardiovascular risk. For some individuals, that risk reduction can be greater than 50%. With the availability of generic forms, these medications are now relatively inexpensive.

  • The cons of statin therapy for primary prevention: It’s important to note that the evidence does not suggest that statin medications cause treated patients to live longer. Moreover, we need to treat 100 or more patients for five or more years to prevent a single patient from having an MI. Those are intriguing numbers because that whole group of 100 patients will experience unwanted side effects of the medications. The rate of muscle-related complications is 5% for all patients and is probably several-fold greater for athletes. Because of muscle-related complaints, many athletes cannot tolerate these medications. As just one example, it might be possible to reduce an athlete’s chance of having a future MI by 50% -- say, from 5% to 2.5% -- but it would obviously be wise to ask if that small reduction, in absolute terms, is worth the potential adverse effects of the statin medications.

If you find yourself in this situation, you should have a careful discussion with your doctor(s) about the benefits and risks of statin therapy as you work to settle on a course of action that is best for you. Come to that discussion knowledgeable about the issues and you’ll be in the best position to choose the best course of action.


Larry Creswell, M.D., is a cardiac surgeon and Associate Professor of Surgery at the University of Mississippi Medical Center in Jackson, Mississippi. In addition to his regular column on Endurance Corner, he maintains The Athlete's Heart blog to offer information about athletes and heart disease in an informal way and to encourage exchange and discussion that will help athletes build a heart-healthier lifestyle. You can contact him at lcreswell@umc.edu.
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