Medical information from The Chaim Society: Statins why they do more than lower cholesterol

By Mindy Frishman, BS, M3

Florida State University College of Medicine

Chaim Society member

and

Dr. Solomon Saul, DO, Family Medicine

co-founder, The Chaim Society, Orlando

Heart disease remains the leading cause of death in the United States. Yet one of the most effective tools we have to prevent heart attacks is often misunderstood: Statins.

Many people believe statins simply lower cholesterol numbers. While that is true, modern research has taught us that their greatest benefit may be something even more important—stabilizing dangerous plaque inside the arteries.

The real cause of most heart attacks

Heart attacks do not usually occur because an artery slowly becomes blocked over many years until blood flow stops. Instead, most heart attacks occur when cholesterol-filled plaque within the artery suddenly ruptures.

When this rupture occurs, the body forms a blood clot over the damaged area. The clot can rapidly block the artery, cutting off blood flow to the heart muscle and causing a heart attack which is why most heart attacks appear suddenly.

Think of plaque like a pimple on the inside wall of an artery. A plaque may not be causing significant blockage, but if it becomes inflamed and ruptures, it can trigger a medical emergency.

How statins help

Statins (e.g. Lipitor [Atorvastatin] Crestor [Rosuvastatin] Zocor [Simvastatin]). lower LDL cholesterol, often called “bad cholesterol.” Lower LDL means less raw material available to build new plaque.

However, statins also have another critical effect: they reduce inflammation within existing plaque and help create a tougher, more stable outer covering. This makes plaques less likely to rupture and cause heart attacks.

In other words, statins do not simply change a laboratory number—they help transform dangerous plaque into more stable plaque.

This is why studies consistently show that statins reduce the risk of heart attack, stroke, and cardiovascular death, even in some patients whose cholesterol levels are not dramatically elevated.

Why cholesterol tests don’t tell the whole story

A common misconception is that a normal cholesterol test predicts there is no heart disease.

Unfortunately, that is not always true.

Two people can have identical cholesterol numbers but very different amounts of plaque in their arteries. Genetics, blood pressure, diabetes, smoking history, inflammation, and age all influence plaque development.

Cholesterol levels tell us about one risk factor. They do not directly show us whether plaque is already present.

What does a stress test actually tell us?

Stress test is where a patient runs on a treadmill and the heart is looked at to see if the heart muscle is not getting enough blood flow. Many patients assume that a normal stress test means they have “clean arteries.” This is one of the most common misunderstandings in cardiology.

A stress test is designed to determine whether blood flow to the heart becomes limited during exercise or stress and is good at deciphering if chest pain is coming from the heart. In general, a stress test becomes abnormal when a blockage is severe enough—often around 70 percent or greater—to significantly reduce blood flow. An abnormal or positive stress test may trigger further tests such as a Cardiac catheterization or CT Angiography where blockages can be identified, and if needed stents placed to restore blood flow.

This means a stress test looks for major obstructions. It does not directly detect smaller plaques that may be present throughout the coronary arteries.

As a result, a person can have a completely normal stress test and still have cholesterol plaque in their arteries. In fact, many heart attacks arise from plaques that were not causing significant blockage before they suddenly ruptured.

This explains why a heart attack may happen after a normal stress test. The test may have correctly shown that there were no major flow-limiting blockages at the time, but it could not predict whether a smaller plaque might later become unstable and rupture.

A stress test is an excellent tool for evaluating symptoms such as chest pain or shortness of breath, but it is not a test for all coronary artery disease.

The growing role of the calcium score

One of the most useful advances in preventive cardiology is the coronary artery calcium (CAC) score. This simple CT scan takes only a few minutes and measures calcified plaque in the coronary arteries. Unlike a stress test, which evaluates blood flow, a calcium score looks for evidence that plaque is actually present.

A calcium score of zero is reassuring and generally indicates a very low short-term risk of heart attack. On the other hand, elevated scores suggest that plaque has already developed and that more aggressive prevention may be needed with statin and other medications.

Many patients are surprised to learn they have significant plaque despite feeling well, having normal cholesterol levels, or even having had a normal stress test.

For these individuals, the calcium score can provide a clearer picture of their true cardiovascular risk.

The role of Coronary CT Angiography (CTA)

Another important tool in modern cardiology is coronary CT angiography (CTA).

Unlike a stress test, which evaluates whether blood flow to the heart becomes limited during exercise or stress, CTA allows physicians to directly visualize the coronary arteries themselves and how the blood flows in the artery. Using intravenous contrast and advanced CT imaging, CTA can identify both calcified and non-calcified plaque and determine whether narrowing of the arteries is present.

The CTA is a noninvasive method of evaluating the coronary arteries, like what is done during a cardiac catheterization. While cardiac catheterization remains the gold standard and allows immediate treatment with stent placement, when necessary, CTA can often provide much of the same anatomical information without requiring an invasive procedure.

CTA allows physicians to know the degree of blockage and provides them with valuable information for risk stratification preventative treatment decisions and if more aggressive cholesterol lowering therapy is needed.

Personalized prevention

Modern preventive medicine is moving away from treating laboratory values in isolation and toward understanding the whole patient.

When deciding whether a statin is appropriate, physicians consider multiple factors including age, blood pressure, diabetes, family history, smoking status, cholesterol levels, and a coronary calcium score showing the presence of atherosclerotic disease.

The goal is not simply to lower cholesterol. The goal is to identify plaque early, stabilize it, and prevent the first heart attack before it ever happens.

The bottom line

We now understand that statins are much more than cholesterol-lowering drugs. They help stabilize plaque, reduce inflammation, and significantly lower the risk of heart attacks and strokes.

Cholesterol testing remains important, but it tells only part of the story. A stress test evaluates blood flow and helps identify major blockages. A calcium score helps reveal whether plaque is present at all. Together, these tools provide a much more complete picture of cardiovascular risk.

With modern technology we now have a more initialized approach to prevent a future heart attack. Understanding your risk, detecting plaque early, and taking preventive action can make all the difference.

For more information, contact: chaimsociety@gmail.com.