By Kym McNicholas, CEO, Global PAD Association
To address these concerns head-on, I recently sat down with vascular surgeon Dr. Lily Johnston on NextGenMD to tackle the most pressing questions patients have about these medications. The conversation was illuminating and, as always with Dr. Johnston, rooted in both science and practical patient care (Watch video above!)
Why Statins for PAD Patients?
One of the most common questions we receive from patients is straightforward: “If my cholesterol is normal, why do I need a statin?”
Dr. Johnston’s answer is clear: “If you have a diagnosis of PAD or coronary disease, you are on it because it is guideline medical therapy to lower your LDL-C by 50%, no matter what that starting value is.”
This might seem counterintuitive, but the guidelines from major medical organizations, including the American College of Cardiology, the American Heart Association, and the Society for Vascular Surgery, are quite specific. Their 2024 guidelines recommend high-intensity statin therapy for anyone with diagnosed plaque in their arteries – whether in peripheral arteries (PAD), coronary arteries (heart disease), or carotid arteries (affecting blood flow to the brain).
Importantly, what appears as “normal cholesterol” on a basic lipid panel doesn’t tell the complete story. As Dr. Johnston explains, “If you have normal cholesterol in a basic lipid panel, that doesn’t mean that your cholesterol is necessarily normal. It may take looking at not just the quantity of the LDL particles, but also the quality.”
Advanced lipid testing provides a more comprehensive picture by examining:
- Particle count (which is more informative than simple levels)
- Particle size (smaller particles tend to be more dangerous)
- Other particles like Lp(a)
- Triglycerides and HDL (which indicate metabolic status)
“Normal cholesterol in a basic lipid panel is not really as helpful as those more advanced measures,” Dr. Johnston emphasizes. These detailed assessments can reveal cardiovascular risks that might be missed in standard testing.
Beyond Cholesterol: The Anti-Inflammatory Effect
What many patients don’t realize is that statins do more than just lower cholesterol. As Dr. Johnston explains, “We know from the JUPITER trial that high-sensitivity C-reactive protein (HSCRP) will be lowered by the addition of therapy.” This means statins are actually fighting inflammation in your arteries.
“Those patients who get the most benefit actually get reduction in both their inflammatory markers like HSCRP and in their LDL-C,” Dr. Johnston points out. “Those were the patients who had the most benefit in that trial.”
This dual action – lowering both cholesterol and inflammation – makes statins particularly valuable for PAD patients. The medication isn’t just addressing the “smoke” (cholesterol numbers); it’s helping put out the “fire” (inflammation) that’s damaging your arteries.
Which Statin Is Right for You?
There are several statins available, but two are considered high-intensity options:
- Rosuvastatin (Crestor): This water-soluble statin is less likely to cross the blood-brain barrier, which may make it less likely to cause cognitive side effects.
- Atorvastatin (Lipitor): Another high-intensity option that’s commonly prescribed.
Dr. Johnston notes that Simvastatin is still commonly prescribed but doesn’t see “a good reason to use it unless patients are intolerant to Atorvastatin or Rosuvastatin.”
For those experiencing muscle pain (a common side effect), Pitavastatin might be an option. “It doesn’t create quite as much LDL-C reduction, but it also tends to be the least likely to induce the myalgia or the muscle pain that many patients get,” explains Dr. Johnston.
Managing Side Effects
Speaking of side effects, muscle pain (myalgia) is one of the most common concerns for patients taking statins. For those experiencing this side effect, Dr. Johnston offers several approaches:
- Optimizing vitamin D and CoQ10 status: “They are not guideline-directed interventions or therapy. They are low-risk and potentially high-yield interventions to minimize that risk.”
- Dose adjustment: “Myalgia risk can be dose-dependent,” notes Dr. Johnston. Some patients who cannot tolerate higher doses may do well on lower doses, potentially combined with other medications.
- Alternative medications: These include Ezetimibe (which prevents cholesterol reabsorption in the intestines) or PCSK9 inhibitors like Repatha.
- Bempedoic acid: A newer option that “does not seem to be active in the muscles the way that statins are.”
How can you tell if muscle pain is from the statin or just coincidental? Dr. Johnston recommends a simple approach: “I would recommend stopping for two weeks, keeping a diary of your symptoms before you stop, then during that washout period of a couple of weeks, and then restarting and seeing what changes with your symptoms.”
Addressing Common Concerns
Will statins cause diabetes?
This is a legitimate concern. “The answer to that is probably yes,” acknowledges Dr. Johnston. “There is evidence that, especially at high doses, the statins do cause worsening insulin resistance.”
However, she adds that the risk can be mitigated with “really aggressive nutritional strategies that help us reduce our insulin burden.” The risk must be balanced against the benefits, particularly right after a cardiac or limb event.
Do statins cause memory problems?
“There have been a couple of case reports of individual patients who’ve had severe cognitive issues after initiation of statin therapy,” notes Dr. Johnston. “Those were reversible the minute they stopped, several days after they stopped that statin therapy.”
However, she emphasizes: “Overwhelmingly, this is not a side effect that we see. Probably statins contribute to a reduced risk of dementia over time, probably related to reduced vascular dementia, reduced stroke rate or silent strokes.”
If cognitive effects do occur, they should resolve when the medication is stopped, and alternatives can be considered.
Why hasn’t my leg pain improved with statins?
This is a common misconception about what statins do. Dr. Johnston explains: “The statin is directed at preventing the narrowing or blockage that you already have from getting worse.” It’s not designed to immediately improve symptoms or clear existing blockages.
“If you have an occlusion somewhere, obviously that’s not gonna go away, but there will be other vascular beds, other areas where you do have narrowing or disease, and the job of the statins is to prevent that from getting worse.”
For symptom improvement, walking remains the primary intervention to develop collateral circulation over time. As Dr. Johnston explains, “That is a slow, long process, but I would not expect that the initiation of statin therapy will improve the walking.”
She adds, “I tell most patients, you’ll probably still have pain with walking, but you may be able to walk further before that happens and require less time to recover. So just managing expectations that that pain won’t go away completely, but you may get more distance and you may have shorter recovery as your collateral circulation improves.”
Beyond Statins: Additional Options
If statins aren’t tolerated or don’t achieve the desired 50% LDL-C reduction, several other options exist:
- Ezetimibe: A pill that helps prevent reabsorption of cholesterol in the intestinal tract.
- PCSK9 inhibitors (Repatha, Praluent): These powerful injectable medications “help us get that LDL receptor upregulated and clear more of those LDL particles out of circulation.” Dr. Johnston notes they “do not seem to have as many of the side effects as the statin class, and they are absolutely included now as part of our guidelines.”
- Bempedoic acid: A newer medication that lowers LDL-C without the muscle effects of statins.
- Supplements: Options like red yeast rice and citrus bergamot can help lower cholesterol, though Dr. Johnston cautions that these “do not have outcomes data that they will reduce your cardiac event risk or your risk of limb loss.”
Regarding supplements, Dr. Johnston adds an important caveat about quality: “Getting [red yeast rice] from Amazon is not my favorite option because I don’t know who made it or whether it’s been third-party tested and there are heavy metals in it or whether what’s in it is really red yeast rice or just something else.” If you choose supplements, find “a high-quality, third-party tested source.”
A Holistic Approach
Perhaps the most important takeaway from my conversation with Dr. Johnston is that statins – while important – are just one piece of the puzzle. “Even though I’m spending all this time talking about statins, that is a small part of what I do in my practice because it’s not enough for most people,” she emphasizes.
The conversation should dig deeper: “Doctor, let’s sit and let’s map out all of the different reasons why I may be having these issues with plaque building up.” This might include investigating:
- Genetic & family history
- Tobacco/Nicotine exposure
- Sleep Aanea
- Hypercoagulability issues (which might require hematology consultation)
- MTHFR mutations and homocysteine levels (which my Dad’s dietician as “like nails on your artery walls”)
- Lp(a)
- Metabolic health factors
- Diet and exercise optimization
Dr. Johnston shares a telling perspective: “It breaks my heart when people say 'my symptoms are worse.’ ‘I’m doing what the doctor said’. ‘I don’t believe in this anymore.'" Dr. Johnston adds, “It doesn’t mean it’s not important, but it may mean that it’s not enough.”
As I often remind patients, statins are a bandaid – an important one that’s part of guidelines and necessary for many patients – but you’ve got to address the root cause: “What is damaging your arteries in the first place? What is irritating those arteries? What’s leading to the plaque buildup?”
A Temporary Measure?
Some patients may not need to be on statins forever. I shared a story about my father, who was initially prescribed a statin after his heart disease diagnosis. His doctor made a deal with him: “Let’s put you on a statin until you can actually get all of your risk factors in order.”
They determined my father had more of a “cholesterol reabsorption problem” than a liver production problem. By adding more fiber to his diet and increasing his bowel movements to excrete the bad cholesterol, he’s been able to manage without the medication – though with the understanding that he’d go back on it if his numbers increased.
Dr. Johnston affirmed this approach, noting: “Especially right after an acute event, so a heart attack, a limb revascularization, or an acute limb ischemia event, that is really the time to acknowledge that we need every tool in our arsenal to reduce the inflammation, to stabilize that inflammation, angry unstable plaque or that brand new stent.”
She adds, “Maybe the answer is we’re going to do that temporarily and calm that fire down that’s on the inside of that artery wall. And then over time, as we can optimize our nutrition, optimize our exercise and our sleep apnea, get that treated and do our stress reduction and recovery and all of those things, then yes, we can back down on our medical therapies.”
Questions to Ask Your Doctor
If you’ve been prescribed a statin, Dr. Johnston recommends asking:
- What side effects might I experience?
- Are there alternative medications I should consider?
- What’s the long-term plan? Will I be on this medication forever?
- Should we do advanced lipid testing before starting?
- When will we follow up to check my levels and adjust if needed?
Dr. Johnston emphasizes the importance of regular follow-up: “I would recheck in six weeks or eight weeks, see if we’re getting that greater than 50% reduction. And if not, then we decide if we’re going to escalate therapy.”
I always remind patients to schedule medication reviews every six months to ensure your treatment plan remains appropriate for your specific needs. This gives you an opportunity to discuss any side effects, check for nutrient deficiencies (like CoQ10 depletion), and ensure your medications are working as intended.
Making Your Decision
Ultimately, as Dr. Johnston emphasizes, the decision to take a statin is yours: “I am here as an educator. I am here to provide options and to tell my patients what we think we know to the best of our scientific ability in the current day and age.”
What we do know is that statins reduce adverse cardiac events like heart attacks and limb events like amputation. They help stabilize existing plaque and reduce inflammation. But they’re most effective when part of a comprehensive approach that includes nutrition, exercise, stress reduction, and management of all cardiovascular risk factors.
If you have questions about your PAD treatment plan or need guidance on finding the right specialist, call our Leg Saver Hotline at 1-833-PAD-LEGS (723-5347). Our team is ready to help you navigate your PAD journey with the most current, evidence-based information available.
This article is based on a NextGenMD episode featuring Dr. Lily Johnston, vascular surgeon. While we strive to provide accurate information, always consult with your healthcare provider before making changes to your medication regimen.