‘The lower the better’ revisited: low-density lipoprotein and lipoprotein(a)

Abstract

The cholesterol hypothesis is one of the most successful concepts in medicine that radically changed care and outcome in cardiac patients. In spite of all the evidence, however, there is still some scepticism from the media, patients, and physicians alike regarding broad use of statins, particulary at high dosages. Whether the fear of side effects from such an intervention is justified is addressed in a Current Opinion entitled ‘Adverse effects of statin therapy: perception vs. the evidence—focus on glucose homeostasis, cognitive, renal and hepatic function, haemorrhagic stroke, and cataract’ by François Mach and colleagues from the European Atherosclerosis Society Consensus Panel. They evaluated in a literature search covering 2000–2017 possible side effects of long-term statins on glucose homeostasis, cognitive, renal and hepatic function, and risk for haemorrhagic stroke or cataract.6 In randomized trials and genetic studies, statins are associated with a modest increase in new-onset diabetes of ∼1/1000 patient years; this risk is higher in the metabolic syndrome or pre-diabetes. In contrast, statins do not adversely affect cognitive function, even at very low levels of LDL-cholesterol (LDL-C), nor do they deteriorate renal function or cause cataract. Transient, clinically unimportant increases in liver enzymes occur in 0.5–2% on statins, while idiosyncratic liver injury is extremely rare. There is no increased risk of haemorrhagic stroke in individuals without cerebrovascular disease, while a small increase in risk cannot be excluded in those with prior stroke. Thus, long-term statin treatment is remarkably safe, with a low risk of clinically relevant adverse effects in the presence of impressive cardiovascular benefits of these drugs.