Is it advisable for a 50-year-old man with hypercholesterolemia (high cholesterol) to opt for holistic approaches instead of taking statins (HMG-CoA reductase inhibitors), given his family history of coronary artery disease, specifically his father's triple bypass surgery at a similar age?

From the Guidelines

I strongly recommend that your husband reconsider taking statins given his significant risk factors, as they are proven to reduce cardiovascular events by 25-35% and are generally well-tolerated 1. Having a father who needed triple bypass surgery in his 50s indicates a strong family history of heart disease, and his long-standing high cholesterol combined with his current age of 50 puts him at considerable risk. While holistic approaches like diet changes (Mediterranean or DASH diet), regular exercise (150 minutes weekly), weight management, and stress reduction techniques can help, they often aren't sufficient for someone with his risk profile. Some key points to consider include:

• The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol recommends statin therapy for patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL) and for adults 40 to 75 years of age with diabetes mellitus and an LDL-C level of 70 mg/dL or higher 1.
• The guideline also recommends a clinician-patient risk discussion before starting statin therapy, which should include a review of major risk factors, risk-enhancing factors, and the potential benefits and risks of statin therapy 1.
• Statins such as atorvastatin (10-80mg daily) or rosuvastatin (5-40mg daily) are effective in reducing LDL-C levels and have been shown to reduce the risk of cardiovascular events in patients with high cardiovascular risk 1.
• Side effects like muscle pain occur in only about 5-10% of patients and can often be managed by adjusting dosage or trying a different statin 1. A compromise might be starting with a low-dose statin while simultaneously implementing lifestyle changes. Statins work by blocking an enzyme that produces cholesterol in the liver, effectively lowering LDL ("bad") cholesterol and reducing inflammation in blood vessels, which helps prevent plaque buildup that can lead to heart attacks and strokes. It's essential to weigh the benefits and risks of statin therapy and consider your husband's individual risk factors and medical history when making a decision about starting statin therapy 1.

From the Research

Statins and Alternative Treatments

• Statins are commonly prescribed to lower cholesterol levels and reduce the risk of cardiovascular disease 2, 3, 4.
• However, some patients may not tolerate statins or may not reach their optimal LDL goals despite taking statins 3, 5.
• In such cases, alternative treatments such as ezetimibe, PCSK9 inhibitors, or a combination of these medications may be considered 2, 3, 4, 5.

Holistic Approaches

• There is limited research on the effectiveness of holistic approaches in lowering cholesterol levels and reducing cardiovascular risk 2, 3, 4, 5, 6.
• While some patients may prefer holistic approaches, it is essential to consult with a healthcare professional before making any changes to their treatment plan.

Combination Therapies

• Combination therapies, such as statins and ezetimibe, have been shown to be effective in lowering LDL levels and reducing cardiovascular risk 3, 5.
• PCSK9 inhibitors, which can be used in combination with statins, have also been shown to be effective in lowering LDL levels and reducing cardiovascular risk 2, 4, 6.
• Oral PCSK9 inhibitors are currently being developed and may provide a convenient alternative to injectable PCSK9 inhibitors 6.

Patient Adherence

• Patient adherence to medication is crucial in achieving optimal LDL levels and reducing cardiovascular risk 2, 5.
• Fixed-dose combinations, such as atorvastatin and ezetimibe, may improve medication adherence and be beneficial for patients who cannot reach their lipid targets with maximally tolerated statin doses 5.