Should I take statins if I have (not yet) had a heart problem?

Statins are cholesterol-lowering medications that are also prescribed to people who have never had a heart attack or stroke but do have an elevated risk of one. This is called 'primary prevention'. A large meta-analysis of 22 randomised trials involving more than 90,000 participants shows that, in people with elevated cardiovascular risk, statins reduce the chance of a heart attack by approximately 33% in relative terms (absolute difference: roughly 0.85 percentage points), and the chance of a stroke by approximately 22% in relative terms (absolute difference: 0.39 percentage points). Overall mortality fell by approximately 8% in relative terms, which amounts to roughly 0.35 percentage points in absolute terms over the study period of a few years on average. (PMID 35997724)

An important practical finding: it takes an average of 2.5 years of statin use in 100 people to prevent one serious cardiovascular event in one person. That may sound modest, but for someone at high risk the difference can be significant. In a meta-analysis focused specifically on people aged 50 to 75, however, there was no evidence of an effect on overall mortality; only one of the eight studies examined demonstrated this. The protective effect on mortality has therefore not yet been fully established in people in that age group. (PMID 33196766)

The decision to use statins depends strongly on your personal risk profile. The United States Preventive Services Task Force (USPSTF) recommends statins for adults aged 40 to 75 who have at least one risk factor (such as high blood pressure, elevated cholesterol, smoking, or diabetes) and a calculated 10-year risk of a cardiovascular event of 10% or higher. At a risk of 7.5 to 10%, the recommendation is more selective: decide together with your doctor based on your individual situation. For people aged 76 and older without heart disease, there is simply insufficient evidence to make a recommendation. (PMID 35997723)

Side effects exist and must be named honestly. Statins slightly increase the risk of self-reported muscle pain (approximately 15 extra cases per 10,000 patients per year), but clinically confirmed muscle disorders were not found significantly more often. Liver function abnormalities (measured via blood values) occur somewhat more frequently (approximately 8 extra cases per 10,000 per year). Small increases in kidney function abnormalities and eye conditions have also been found, but those findings are based on few studies and must be interpreted with caution. The risk of type 2 diabetes is not significantly increased overall, although one study did find a 25% higher risk with high-intensity statins. According to the largest meta-analysis, these side effects on balance do not outweigh the protective effects. (PMID 34261627)

There are also critical voices. A group of researchers around Ravnskov argues that the causal evidence for LDL cholesterol as a cause of cardiovascular disease is weaker than is often presented, and that statin studies make their benefits look optically larger by using relative rather than absolute risk reduction. This is a minority position that is disputed by the large majority of cardiologists, but it does illustrate that the absolute effects are modest, and that presenting relative figures can make reality appear different from what it actually is. (PMID 30198808, 25672965)

A specific subgroup deserves separate attention: people with type 1 diabetes without prior heart disease appear to benefit clearly from statins. In an observational study involving more than 20,000 participants, statin use was associated with 1.66 to 3.48 percentage points less mortality and 1.63 to 2.69 percentage points fewer cardiovascular events over ten years, respectively, with a very low risk of serious side effects. The effect was greater in women, in people aged 40 and older, and at higher LDL values. (PMID 40930617)