What are the risks of stopping statin (HMG-CoA reductase inhibitor) therapy?

Risks of Stopping Statin Therapy

Stopping statin therapy significantly increases your risk of cardiovascular death, myocardial infarction, and stroke—particularly in patients with established cardiovascular disease, where discontinuation more than doubles cardiovascular events, quadruples stroke risk, and nearly quadruples mortality. 1

Critical Risk Stratification: When Stopping is Dangerous vs. Reasonable

HIGH RISK: Do NOT Stop Statins

In patients with established atherosclerotic cardiovascular disease (history of MI, stroke, TIA, coronary revascularization, or peripheral arterial disease), statins should NOT be discontinued except for severe intolerance or end-of-life care. 2, 3

• Discontinuation in secondary prevention patients leads to more than two-fold increased cardiovascular events 1, 2
• Four-fold increased stroke risk 1, 2
• Nearly four-fold increased mortality 1, 2
• Statin-adherent patients are half as likely to experience subsequent myocardial infarction compared to non-adherent patients 1
• In younger patients (<65 years), the reduction in myocardial infarction with adherence is even greater 1

MODERATE RISK: Consider Continuation

For primary prevention in adults 65-75 years without established cardiovascular disease, continue statins as evidence supports benefit in this age group. 4

LOWER RISK: Discontinuation May Be Reasonable

In adults ≥75 years of age, it may be reasonable to stop statin therapy when functional decline (physical or cognitive), multimorbidity, frailty, or reduced life-expectancy (<3 years) limits the potential benefits. 1, 2, 4

• The time-to-benefit for statins (typically 2-3 years) exceeds remaining lifespan in frail elderly 2, 4
• For primary prevention in adults >85 years, discontinuation is reasonable in most cases, as evidence for benefit is extremely limited with only 8% of trial participants being >75 years in major trials 2, 4
• Measuring coronary artery calcium (CAC) may help guide decisions—a CAC score of zero in middle-aged adults (40-55 years) with borderline risk or older adults (55-80 years) with low risk burden may support withholding or discontinuing therapy 1, 2

Specific Clinical Scenarios Where Discontinuation Has Limited Evidence

National guidelines highlight lack of benefit data for statin therapy in patients with chronic kidney disease receiving dialysis, heart failure with reduced ejection fraction (NYHA class II-IV ischemic systolic heart failure), making discontinuation consideration reasonable in these populations. 4, 5

Alternatives to Complete Discontinuation

Rather than stopping entirely, consider these strategies to maintain cardiovascular protection while addressing tolerability:

• Dose reduction: If high-dose statins cause side effects, reduce to moderate or low-intensity rather than complete cessation 2
• Alternative statin: Trial different statins if myalgia or other side effects occur—different statins have varying myopathy risk profiles 2, 3
• Add ezetimibe: Allows lower statin dosing while maintaining lipid control 2

Common Pitfalls to Avoid

• Abrupt discontinuation after acute cardiovascular events: This is associated with increased cardiovascular morbidity and mortality 3
• Stopping reflexively in elderly patients: Continue in robust elderly with established cardiovascular disease and good functional status 4
• Attributing pre-existing symptoms to statins: Obtain baseline history of muscle symptoms before starting therapy to avoid unnecessary discontinuation 3, 4
• Permanent discontinuation without rechallenge: After symptom resolution, rechallenge with the same or different statin at lower dose to establish causality 3, 4

The Magnitude of Benefit Being Lost

When you stop statins in appropriate candidates, you lose substantial protection:

• 14% reduction in all-cause mortality (absolute risk reduction 0.40%) 6
• 31% reduction in cardiovascular mortality (absolute risk reduction 0.43%) 6
• 29% reduction in stroke (absolute risk reduction 0.38%) 6
• 36% reduction in myocardial infarction (absolute risk reduction 0.81%) 6
• 30% reduction in composite cardiovascular outcomes (absolute risk reduction 1.39%) 6

These benefits are consistent across demographic and clinical subgroups, including populations without marked hyperlipidemia (total cholesterol <200 mg/dL), with absolute benefits higher in subgroups at higher baseline risk. 6