High cholesterol may have played a role in your recent heart event. Because high cholesterol levels can be linked to heart attack, stroke, and other coronary events, it’s very important that you keep your cholesterol levels under control once you’ve had a heart issue.
You might have been taking medication to lower your cholesterol. Or maybe you were working on lifestyle changes like diet and exercise. Or maybe you weren’t treating your cholesterol at all or didn’t even know it was high.
But now that you’ve had a coronary event or heart issue, you’ll work with your doctor on a treatment plan to keep your cholesterol at healthy levels.
Healthy Cholesterol Levels
In general, a healthy total cholesterol level for adults ranges between 125 and 200 mg/dL. Guidelines suggest that your LDL, or “bad,” cholesterol levels be under 100 mg/dL and your HDL, or “good,” cholesterol be 40 mg/dL or higher for men and 50 mg/dL or higher for women.
But these are just guidelines. Healthy cholesterol numbers are not the same for everyone.
When you’ve had a cardiac event, your doctor may suggest much lower cholesterol targets. For example, if you’ve had a heart attack or stroke, your "bad” LDL cholesterol target is typically lower than 70 mg/dL.
Some doctors suggest an even lower target, like a "bad” LDL cholesterol level less than 55 mg/dL. Your doctor will work with you to develop the best target cholesterol goals for you.
Understanding Statins
Statins are the most common type of medicine used to treat cholesterol. They work by lowering the amount of cholesterol your liver makes—specifically the LDL, or “bad,” kind.
Statins also slow down how much cholesterol builds up in your arteries. These medicines can help lower the chance of stroke or heart attack if you already have high “bad” LDL cholesterol levels.
Eight statins that have been approved in the U.S. to treat cholesterol. Your doctor will choose which statin is best for you based on how much lower your LDL cholesterol level needs to go.
Your doctor will also consider if you have any other health issues and what other medications you take.
Statin Side Effects
Like all drugs, statins might trigger some side effects. Most side effects are mild and usually go away after you’ve been taking the drug for a period of time.
Sometimes statins can cause muscle aches, make you tired, or your brain might feel a little foggy. There’s a slight chance of headaches, stomach issues, or sleep problems. In rare cases, statins can cause liver damage or increase your blood sugar.
Keep your doctor posted on any issues. But don’t just stop taking statin medicines without talking to your doctor first. You might have to switch to a different statin if you have side effects with the first one you try.
Your doctor might suggest regular liver tests to make sure statins aren’t having an impact.
All About Statin Intensity
Usually, the higher the dose of a statin, the more it’s able to work to lower your LDL, or “bad,” cholesterol. But some statins lower “bad” LDL cholesterol better than others.
High-intensity, moderate-intensity, and low-intensity statins differ by how the medicines work.
Some statins can have different intensities depending on the dose. For example, atorvastatin (Lipitor) works as a moderate-intensity statin if you take between 20 milligrams and 40 milligrams each day. But at higher doses between 40 milligrams and 80 milligrams a day, atorvastatin also works as a high-intensity statin.
If you’ve had a coronary event, like a heart attack or stroke, doctors recommend high-intensity statin therapy no matter what your LDL cholesterol levels are.
Studies have looked at patients who have recently had a serious heart issue. Following a high-intensity treatment plan helps protect against major cardiac events better than taking less intense dosages and medication.
Other Treatments
Statins aren’t the only medicines used to treat and prevent unhealthy cholesterol after a heart event.
When you have had a heart attack, stroke, or other heart issue, your doctor will almost always try a high-intensity statin first. If your LDL cholesterol is still 70 mg/dL or higher, you may be prescribed another type of cholesterol-lowering medicine.
These cholesterol-lowering medications can often be taken along with your statin.
Ezetimibe lowers the amount of cholesterol your body absorbs from food.
Bile acid-binding drugs keep acids from getting into your blood and help your liver take extra cholesterol.
PCSK9 inhibitors are injected under your skin. They stop a protein, PCSK9, that keeps LDL cholesterol from being absorbed, so it lowers your “bad” cholesterol levels.
Niacin or nicotinic acid is a vitamin that can lower the amount of fats your liver makes. Niacin can also lower your LDL cholesterol and triglycerides (blood fat). Only take niacin if your doctor tells you to take this supplement.
ACL inhibitors, such as bempedoic acid, block your liver from making cholesterol. These medicines don’t get into the muscles and may work better for people who have side effects with statins. These medications can be taken with ezetimibe or with statins.
Fibrates lower triglycerides and can lessen LDL cholesterol to some extent.
Other newer injectables include inclisiran (Leqvio), which changes the way your genes work. Inclisiran is a small interfering RNA (siRNA) medication that turns off PCSK9 in your liver, removing more cholesterol from your blood. This “interference” helps lower LDL cholesterol when statins or other drugs don’t work.
Treatment Costs
Statins are typically covered, at least in part, by insurance policies. But when you’re prescribed newer medications, sometimes the costs can be steep. Injectable medicines, like PCSK9 inhibitors, can be especially costly.
Luckily, prices have decreased since the meds were released a few years ago. For example, the monthly cost for evolocumab (Repatha), an injectable cholesterol-lowering medication, is about $561.49. But insurance often pays some of the cost, and pharmaceutical companies offer rebate cards that can lower the monthly price to about $5.
When prescribed a new medicine, check with the manufacturer and your local pharmacy for similar rebates so that your cholesterol-lowering drugs are affordable.
If you think you’ll be unable to afford to continue taking medicine, don’t just stop. Talk to your doctor to see what options are available. Cholesterol management is so critical, particularly after a coronary event.
Lifestyle Changes Help Keep Cholesterol in Check
Even though you manage your cholesterol with medication, lifestyle changes can still help you reach your cholesterol goal. There are many things you can do to help keep your cholesterol in check.
In addition to taking medication, many heart-healthy habits can help lower your risk of another coronary event.
Eat a nutritious diet. Eat a heart-healthy diet low in saturated fats, fish, and low-fat dairy. Choose more fruits and vegetables, whole grains, and unsaturated fats, including foods like nuts, avocados, and vegetable oils.
Quit smoking and avoid alcohol. Stop smoking. And if you don’t drink alcohol, don’t start. If you drink alcohol, at least limit how many drinks you have.
Get moving. Exercise regularly. Try to get 2 1/2 hours each week.
Rest soundly. Get enough sleep — 7 to 9 hours each night — and find healthy ways to manage stress.
Reach your weight goal. Lose extra pounds and get to your recommended weight target.
Show Sources
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SOURCES:
Yale Medicine: “9 Things You May Not Know About Cholesterol.”
Journal of the American Heart Association: “Lipid testing and statin dosing after acute myocardial infarction.”
National Heart, Lung, and Blood Institute: “Blood Cholesterol: Treatment.”
Harvard Health Publishing: “Statins: Types, Uses, Side Effects, and Alternatives,” “Understanding Statin Intensity,” “The Very High Cost of Very Low Cholesterol.”
American College of Cardiology: “2018 Guideline on the Management of Blood Cholesterol.”
New England Journal of Medicine: “Intensive versus moderate lipid lowering with statins after acute coronary syndromes.”
Mayo Clinic: “Statin Side Effects: Weigh the Benefits and Risks.”
American Heart Association: “Cholesterol Medications,” “Prevention and Treatment of High Cholesterol (Hyperlipidemia).”
CDC: “Treat and Manage High Cholesterol,” “Cholesterol-Lowering Medicines.”
Cleveland Clinic: “Ezetimibe Tablets.”
American Journal of Cardiovascular Drugs: “Cost effectiveness of inclisiran in atherosclerotic cardiovascular patients with elevated low-density lipoprotein cholesterol despite statin use: a threshold analysis.”
Roger S. Blumenthal, MD, FACC, the Kenneth Jay Pollin Professor of Cardiology; director, Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore.
Aaron Troy, MD, MPH, cardiovascular disease fellow, Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore.
Genomic Education Programme, National Health Services (NHS): “RNAi: A New Approach to Combat Cholesterol.”
