Statins ARE Recommended for Women

Debunking the latest Instagram meno-myth

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I’ve been asked multiple times this week about statins for preventing heart disease for women (here, we’ll include the menopause transition onwards). Apparently, there are doctors on social media making claims that statins don't work for women and even going so far as saying that the American Heart Association (AHA) supports this claim.

That’s a bold claim.

I’m not going to bury the lede. It may be a bold claim, but it is an incorrect one. The AHA recommends statins for women (when appropriate), and this was even covered in a lecture at the most recent Menopause Society meeting in 2023.  I wrote about that lecture previously here, and one of my key takeaways from the lecture was that “It’s true that women are underrepresented in studies that address cardiovascular disease, and fewer women have been in trials. Still, enough women have been studied to know that statins work for them.”

However, as I was paraphrasing the cardiologist who gave the lecture, I wanted to do some additional digging to back up my support of statins for women. Of course, I’m not going to go this one alone; I’m going to get a cardiology consult!

What are Statins, and What is the Data for Women?

They are medications that reduce cardiovascular disease and mortality for those at risk of cardiovascular disease. Statins lower low-density lipoprotein (LDL) and stabilize plaques in the blood vessels, and they are used for primary prevention of cardiovascular disease for people at high risk and also for secondary prevention, meaning for those who already have cardiovascular disease. According to Dr. Danielle Belardo, MD, a cardiologist who is an expert in preventive cardiology, the role of statins “in preventing heart disease in women, including postmenopausal women, is supported by significant robust evidence.” 

Dr. Belardo agreed with the expert who lectured at the Menopause Society meeting in 2023, noting, “While early clinical trials of statins included fewer women than men, subsequent analyses and studies specifically focusing on women have shown that statins effectively reduce the risk of major cardiovascular events in women at high risk for heart disease or with established cardiovascular disease, similar to their effect in men.”

The key article that shows the benefit of statins for women looked at data from over 174,000 participants in 27 randomized trials and was published in the Lancet in 2015. While most participants were men, 27%, or 46,675, were women, so this represented a lot of data to evaluate the impact of statins on women. The authors concluded, “In men and women at an equivalent risk of cardiovascular disease, statin therapy is of similar effectiveness for the prevention of major vascular events.” And statins had a similar reduction in all-cause mortality for both women and men. 

In 2015, Professor Peter Weissberg, Medical Director of the British Heart Foundation, commented on the Lancet article when it came out, “This analysis of the effects of statins on 174,000 patients, undertaken by combining results from 27 different trials, shows beyond any reasonable doubt that women gain the same benefits from statins as men. Far too few women realize they are at greater risk of dying from a heart attack than from breast cancer, and this study should reassure them that, if advised by their doctor, they can reduce that risk by taking a statin.”

What About the American Heart Association?

I wasn’t sure about the origin of the claim that the American Heart Association says statins don't work for women. I’d never heard that before, and while I’m not a cardiologist, I am proficient in Google. I found the 2019 American College of Cardiology and AHA Guideline on the Primary Prevention of Cardiovascular Disease, and one of the take-home messages for prevention is:

Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

The guideline does not distinguish between women and men regarding statins, nor does it state that statins are ineffective for women.

The first hit on my Google search was actually a Feb. 2024 AHA article that seems to have been written especially for Heart Month (February) about the undertreatment of heart disease among women.

The article states:

Research shows women continue to be undertreated for cardiovascular problems compared to men. They are less likely to be treated for high cholesterol with statins, which have been shown to lower the risk for heart attacks and strokes. They also are less likely than men to be prescribed blood-thinning drugs to prevent or treat blood clots as treatment for atrial fibrillation.

and 

Statins have helped us make huge improvements in cardiovascular health, but women still aren't getting all the benefit.

Lamenting statins being underprescribed for women is not congruent with a recommendation against statins for women! 

And Dr. Belardo added:

Leading cardiovascular organizations, including the American College of Cardiology (ACC) and the American Heart Association (AHA), recommend statins for both men and women based on specific risk criteria, emphasizing their importance in managing cardiovascular risk.

The only hit I could find for the American Heart Association supposedly not recommending statins comes from a statement paper, which is a review article, not a guideline. Confusingly, the statement paper appears to contradict itself. In one part, the authors state that the current AHA guidelines “do not provide specific recommendations for women and men independently. Therefore, the most recent lipid-lowering guidelines recommend statins as first-line therapy for CVD risk reduction, regardless of sex or menopausal status.” Ok, great, statins are recommended. But they also write, “Data for primary and secondary prevention of atherosclerotic CVD and improved survival with lipid-lowering interventions remain elusive for women, with further study required for evidence based recommendations to be developed specifically for women.”

It’s important to know that statements are generally regarded as think-pieces and are not guidelines for medical care. Dr. Belardo agrees this statement is not a substitute for the guidelines and tells me it should not change how we practice medicine. And that she and her colleagues in preventive cardiology and the AHA all say the data shows statins work for women just as they do for men.

Bottom line: Preventive cardiologists and the AHA recommend statins for women, just as they do for men, and doctors making claims to the contrary could worsen the discrepancy of cardiac care for women. 

References

Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174 000 participants in 27 randomised trials. Lancet 2015;385:1397-1405.

Arnett, D, Blumenthal, R, Albert, M. et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Sep, 74 (10) e177–e232.

El Khoudary SR, Aggarwal B, Beckie TM, Hodis HN, Johnson AE, Langer RD, Limacher MC, Manson JE, Stefanick ML, Allison MA; American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation. 2020 Dec 22;142(25):e506-e532.