Statins vs. supplements: A reckoning

Your recent blood test shows that your LDL (bad) cholesterol is on the high side. Do you take a prescription cholesterol-lowing statin, or choose a dietary supplement that "supports heart health" from the myriad on display at your local drugstore?

Many people choose the latter, which is a source of great consternation for most cardiologists. Why would people shun an inexpensive, safe medication in favor of capsules made from unregulated products in bottles labeled with vague promises? These concerns inspired a recent study (see "Supplement standoff"). "The results clearly show that if you need to lower your LDL, a statin works, and these supplements do not," says Dr. Christopher Cannon, editor in chief of the Harvard Heart Letter.

Cardiologists usually only see people who already have heart disease, and for most of them, statins are a good idea because they lower the risk of a repeat heart attack by about 30%. But what about people without heart disease? Simply having elevated LDL cholesterol doesn't necessarily mean you should be taking a statin, says Dr. Cannon. He uses a person's risk score on the American College of Cardiology's risk calculator (available at /ascvd) to start a discussion about whether taking a statin makes sense. People with a 10-year cardiovascular disease risk of greater than 5% might consider a statin, which the guidelines recommend for people with scores of 7.5% or higher, he explains.

Don't neglect lifestyle changes

But he and other physicians agree that healthy habits — especially following a plant-focused diet and getting regular exercise—should be the foundation of lowering heart disease risk. "For people without heart disease, lowering LDL is not an emergency. I give my patients six months to get a good plan in place and then see how their LDL responds to lifestyle changes," says Dr. Donald B. Levy, medical director of the Osher Clinical Center for Integrative Health at Harvard-affiliated Brigham and Women's Hospital. For some people, starting a statin reduces their incentive to exercise and eat well, he says. Rather than focusing on different ways to minimize their cardiovascular risk, including managing stress and getting sufficient sleep, they worry only about reaching a specific LDL target.

Integrative medicine relies on a combination of well-researched conventional and alternative therapies, with a focus on healing the whole person. People who seek out this type of care are motivated to try nondrug options for a variety of reasons, says Dr. Levy. For instance, some don't trust "Big Pharma." Others are sensitive to medications in general and want to avoid them when possible.

Suspicious supplements

Dr. Levy's advice may include dietary supplements such as red yeast rice and plant sterols—but only under a doctor's supervision and using products tested and vetted by ConsumerLab.com, an independent testing company. Of note: The red yeast rice brand used in the recent study contains none of the active ingredient, a naturally occurring statin-like substance, Dr. Levy points out. What's more, with the exception of red yeast rice and plant sterols, none of the other supplements used in the study are even known to affect LDL. "Taking cinnamon, garlic, or turmeric to lower cholesterol does not make sense," he says. You simply can't trust supplement labels, a problem the FDA is attempting to address (see "Unproven claims on supplements for heart disease").

However, Dr. Levy also prescribes statins when appropriate and notes that compared to other statins, rosuvastatin (Crestor) is less likely to interact with other medications. Potentially harmful interactions are another reason Dr. Cannon is wary about dietary supplements, some of which can interact with heart medications. For example, high-dose garlic supplements may slightly raise bleeding risk when taken with anti-clotting medications such as warfarin (Coumadin) or clopidogrel (Plavix).

The bottom line

After age 45 (if you're a man) or 55 (if you're a woman), get a blood cholesterol test every one to two years. Use the results to assess your risk and talk to your doctor, advises Dr. Cannon. "Discuss whether you need treatment, and figure out together what works, but don't just try something 'natural' on your own," he says.

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