What are the benefits and drawbacks of statins in carotid artery disease? A perspective review

ABSTRACT

Introduction

The prevalence of carotid artery stenosis in the general population is approximately 3%, but approximately 20% among people with acute ischemic stroke. Statins are recommended by multiple international guidelines as the drug of choice for lipid control in people with asymptomatic or symptomatic carotid artery stenosis due to their lipid-lowering and other pleiotropic effects.

Areas covered

This review discusses the guidelines for statin usage as a cornerstone in the prevention and management of atherosclerotic carotid artery disease and the impact of statins on stroke incidence and mortality. Statin side effects, alternative therapy, and genetic polymorphisms are reviewed.

Expert opinion

Statin therapy is associated with a decreased incidence of stroke and mortality as well as improved outcomes for patients treated with carotid revascularization. Statins are a safe and effective class of medications, but the initiation of therapy warrants close monitoring to avoid rare and potentially serious side effects. Lack of clinical efficacy or the presence of side effects suggests a need for treatment with an alternative therapy such as PCSK9 inhibitors. Understanding the interplay between the mechanisms of statins and PCSK9 inhibition therapies will allow optimal benefits while minimizing risks. Future research into genetic polymorphisms may improve patient selection for personalized therapy.

KEYWORDS:

• Statins
• carotid artery disease
• best medical therapy
• low-density lipoprotein cholesterol
• carotid endarterectomy
• carotid angioplasty and stenting
• statin-associated muscle symptoms
• genetic polymorphism

Article highlights

• Statins are essential medications for the prevention and treatment of cardiovascular disease including stroke.

• Statins are competitive inhibitors of hydroxymethylglutaryl-CoA (HMG-CoA) reductase that results in reduced cholesterol synthesis.

• The clinical benefits of statins are due to multiple pleotropic effects on blood vessel walls, including antioxidant, anti-inflammatory, anti-proliferative, and immunomodulatory effects.

• Statins should be used for patients with both asymptomatic and symptomatic carotid disease and should be started in the perioperative period if not beforehand.

• Side effects from statins are unusual and need to be monitored but benefits generally outweigh potential risks.

• Genetic polymorphisms in the CYP450 system or the ApoE gene, as well as other genes, may account for statin variability of efficacy as well as for occurrence of side effects.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

A Dardik was supported by National Institutes of Health Grants R01-HL-144476 and R01-HL-162580, and the resources and use of facilities at the Veterans Affairs Connecticut Healthcare System (West Haven, CT).