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SPECIAL FOCUS y Statins & Lipid Hypothesis

Perspective

Statins stimulate
atherosclerosis and heart
failure: pharmacological
mechanisms
Expert Rev. Clin. Pharmacol. Early online, 111 (2015)

Harumi Okuyama*1,
Peter H Langsjoen2,
Tomohito Hamazaki3,
Yoichi Ogushi4,
Rokuro Hama5,
Tetsuyuki Kobayashi6
and Hajime Uchino7
1
Nagoya City University and Institute for
Consumer Science and Human Life,
Kinjo Gakuin University, 2-1723 Omori,
Moriyama, Nagoya 463-8521, Japan
2
Clinical Cardiology Practice, 1107
Doctors Drive, Tyler, TX 75701, USA
3
Toyama Onsen Daini Hospital,
1-13-6 Taromaru-Nishimachi,
Toyama-city, Toyama 939-8271, Japan
4
Ogushi Institute of Medical Informatics,
12-43-2, Daikancho, Hiratsuka,
Kanagawa 254-0807, Japan
5
Non-Profit Organization Japan Institute
of Pharmacovigilance (Kusuri-no-Check),
Ueshio 5-1-20, Tennouji-ku, Osaka
543-0002, Japan
6
Graduate School of Humanities and
Sciences, Ochanomizu University,
2-1-1 Ohtsuka, Bunkyo-ku, Tokyo
112-8610, Japan
7
Medical Corp. Uchino-kai, 5-10-12
Yahata, Minami-ku, Kumamoto
861-4113, Japan
*Author for correspondence:
Tel.: +81 528 763 840
Fax: +81 528 763 840
[email protected]

In contrast to the current belief that cholesterol reduction with statins decreases
atherosclerosis, we present a perspective that statins may be causative in coronary artery
calcification and can function as mitochondrial toxins that impair muscle function in the heart
and blood vessels through the depletion of coenzyme Q10 and heme A, and thereby ATP
generation. Statins inhibit the synthesis of vitamin K2, the cofactor for matrix Gla-protein
activation, which in turn protects arteries from calcification. Statins inhibit the biosynthesis of
selenium containing proteins, one of which is glutathione peroxidase serving to suppress
peroxidative stress. An impairment of selenoprotein biosynthesis may be a factor in congestive
heart failure, reminiscent of the dilated cardiomyopathies seen with selenium deficiency.
Thus, the epidemic of heart failure and atherosclerosis that plagues the modern world may
paradoxically be aggravated by the pervasive use of statin drugs. We propose that current
statin treatment guidelines be critically reevaluated.
KEYWORDS: atherosclerosis . ATP generation . coenzyme Q10 . heart failure . mitochondrial toxin . selenoprotein
.

statin . statin cardiomyopathy . vitamin K2

The relationship between plasma total cholesterol (TC) and coronary heart disease (CHD) is
not simple. Around 1990, the bad low-density
lipoprotein cholesterol (LDL-C), good highdensity lipoprotein cholesterol (HDL-C)
hypothesis was introduced in clinical trials.
Because the direct assay method to determine
LDL-C was found to be unreliable, LDL-C values are presently calculated by the Friedewalds
equation, LDL-C = TC HDL-C 0.2 
triglyceride (TG; in units of mg/dl), but the
equation is not accurate when the HDL-C and
TG values are extremely high. There are cases
when the formula LDL-C = TC 80 mg/dl is
used. We will use TC and LDL-C without any
further comments, and the latter comprises
roughly two-thirds of the former.
The bad & good cholesterol hypothesis
lost its foundation

The good and bad cholesterol hypothesis is

based on simplified interpretations that LDL
carries TGs and cholesterol to peripheral tissues,
whereas HDL reverse-transports cholesterol to
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10.1586/17512433.2015.1011125

the liver to excrete excess cholesterol to feces,

mostly as bile acids. However, HDL contains
lecithin cholesterol acyltransferase enzyme to
form cholesterol ester, which is transported to
LDL by cholesterol ester transport protein in
plasma. Roughly 1.5 g of cholesterol is required
daily in adults for a variety of essential functions, and 0.3 g (about half of ingested cholesterol) can be obtained from 2 eggs plus 100 g
meat and the rest (~1.2 g), the majority of daily
required amount, is biosynthesized in adult tissues. The cholesterol taken-up by HDL is transferred to LDL, which is redistributed to and
reused by peripheral tissues.
Recently, cholesterol ester transport protein
inhibitors were developed and they were effective in lowering LDL-C/HDL-C ratios but they
were essentially ineffective in preventing
CHD [1]. Moreover, statins or statins plus other
cholesterol-lowering drugs were effective in lowering LDL-C but were essentially ineffective in
preventing CHD [2,3] as will be summarized
below. All these observations go against the
good cholesterol/bad cholesterol hypothesis,

 2015 Informa UK Ltd

ISSN 1751-2433

Perspective

Okuyama, Langsjoen, Hamazaki et al.

Clinical Trials of Statins

Before

and

After

The new penal regulation on clinical trial came into force in EU in 2004
60

30

ASPEN (DM II)

4S

50
ENHANCE (FH)

Coronary artery event (%)

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Secondary
prevention

4D (DM II)

20

40
SEAS (coronary stenosis)
ID
LIP

-PR

E-IT

V
PRO

-ATV

VE-IT

10

PRO

30

R
CA
HPS

PS

CO

V
PS
AT
0 NT- AFCA
8
T
TV

GISSI-FH (HF, heart failure)

CORONA (heart failure,
dialysis)

10

T-

TN

20

S
WO

10

ILLUMINATE (high risk group)

Primary
prevention

OT

ASC

JUPITER (high CRP)

0

40

80

120

160

200

LDL-C level, mg/dl

50

100

150

200

250

LDL-C level, mg/dl

Figure 1. Clinical trials of statins for the prevention of CHD-comparison of the effectiveness reported before and after the
year 2004 when new penal regulations on clinical trials came into effect in the EU. The arrow tail and head represent the LDL-C
level and CHD event of the control and intervention groups, respectively. The major types of the participants are shown in parentheses.
Each clinical trial with statin is shown in abbreviated name.
CHD: Coronary heart disease; CRP: C-reactive protein; DM: Diabetes mellitus; FH: Familial hypercholesterolemia; LDL-C: Low-density
lipoprotein cholesterol.
Modified with permission from Lipid Technology [7].

and we should not try to explain the correlation between plasma

cholesterol levels and CHD events based on this hypothesis.
Since the introduction of statins to clinical medicine in
1987, several kinds of statins were reported to be effective
in lowering LDL-C and also preventing CHD events (mostly
in 1990s). However, unfair and unethical problems were associated with clinical trials reported by industry-supported scientists, and new penal regulations on clinical trials came into
effect in 2004 [4,5]. After 20042005, all clinical trials, performed by scientists relatively free of conflict of interest with
pharmaceutical industries, reported that statins were effective in
lowering LDL-C but no significant beneficial effects were
observed for the prevention of CHD (FIGURE 1). Currently, the
majority of scientists continue to claim that statins are effective
in preventing CHD, but these claims are based on metaanalyses of reports, including those published before the EU
regulation (mostly in 1990s). However, our group did not
adopt the results of industry-supported publications as reliable
in our cholesterol guidelines [6,7]. Thus, we are in a position
not to accept the effectiveness of statins to prevent
CHD (FIGURE 1, left), but rather we support the pharmacological
doi: 10.1586/17512433.2015.1011125

interpretations that statins stimulate the development of atherosclerosis and heart failure. The lines of evidence described
below led us to propose that current statin therapy should be
critically and urgently reevaluated.
Statins are mitochondrion toxic

In mitochondria, subcellular organelles, electron transport chain

and ATP synthesizing enzymes are localized in the inner membranes (FIGURE 2). Fatty acids and sugars are burned (hydrogen is
pulled out) to store energy as ATP. In the electron transport
chain, each hydrogen (H) atom forms an electron (e ) and a
proton (H+), and the electron is transported through complex I
or complex II to coenzyme Q10 (CoQ10) and then to complex
III and finally to complex IV. Protons are concentrated in the
mitochondrial membrane space between the outer and the
inner membranes and they form a gradient that drives
the ATP-synthesizing enzyme ATPase, and the molecular
motor is turned on to generate ATP [8,9].
CoQ10 (both in its oxidized ubiquinone and reduced ubiquinol
forms) and heme A are essential components of the electron
transport chain and are synthesized from prenyl-intermediates in
Expert Rev. Clin. Pharmacol.

Statins stimulate atherosclerosis & heart failure

Perspective

Cytochrome

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Burning sugars (pulling out H)

the cholesterol biosynthetic pathway. Statins inhibit CoQ10 and heme A biosynH+
H+
ATP synthase
thesis, and thereby ATP generation. ATP
H+
H+
is essential for normal heart muscle funcCoQ10
Heme a
tion, metabolism of cellular components
I
IV
III
II
and other activities in cell life. Cholesterol
is a major component of cell membranes,
Complex I
ADP + Pi = ATP
Complex II
functioning to maintain their integrity,
which is likely to be affected by statins.
Thus, statins are mitochondrial toxins
O2 + 4e + 4H+ = 2H2O
making all cells ATP depleted. Because
Burning fatty acids (pulling out H)
+

H= H +e
most mammalian cells depend on mitochondria for their energy metabolism, statins are general cell toxins.
CoQ10 is an essential cofactor in elecInner membranes
tron and proton transport in mitochondrial energy production [810], as well as in
several other aspects of cellular metaboOuter membranes
(cholesterol enriched)
lism [11]. The bioenergetic effect of CoQ10
is believed to be of fundamental imporFigure 2. Statins are mitochondrion toxic. See text for detailed explanations.
tance in its clinical application, particularly
as it relates to cells with exceedingly high
metabolic demands such as cardiac myocytes. The reduced form decreased ATP generation and cellular damage (FIGURE 3). Walter
of CoQ10 (ubiquinol) is recognized to be a clinically relevant Hartenbach, former professor of pathology at Mnchen Uniantioxidant in different cellular compartments, especially the versity, observed cellular damage in the artery well before fatty
mitochondrial membranes [12,13], where it protects mitochondrial plaques (cholesterol accumulation) were formed [15].
In the case of statins, ATP generation is impaired by their inhiDNA from damage. It is well known that mitochondrial DNA is
bition
of CoQ10 and of heme A biosynthesis. Similar to the case
much more vulnerable to oxidative damage than nuclear DNA.
of CHD and familial hypercholesterolemia (FIGURE 3), limited supply of ATP could be a major cause for heart muscle and coronary
Decreased ATP generation & resulting cell damage
artery damage. The impact of statins on heart muscle will be
contribute to the development of CHD in familial
hypercholesterolemia cases & in statin-treated people
The initial pathophysiology of the onset of
CHD
Familial hypercholesterolemia
atherosclerosis has not been well
Statin administration
defined (FIGURE 3). However, any tissue damConditional infection,
age, whether derived from a pathogen or
persistent inflammation,
noninfectious damage, may induce inflam- AGEs, over working, stress
Decreased
mation to repair damaged tissues leading
Impaired LDL-receptor function
prenyl-intermediate levels
to many diseases, including atherosclerosis.
Stenosis of
coronary artery
These inflammatory repair mechanisms
are mediated through Toll-like receptors
Heme A, SelenoVitamin
Restricted supply of energy
in response to activators produced by
CoQ10
proteins
K2
source
infections, hypoxicischemic damage,
Restricted
overwork and/or stress and elevated
supply of energy
and oxygen
advanced glycation end products [14]. The
Peroxidative
Decreased ATP generation
Matrix Gla
enzymes
associated coronary artery stenosis leads to
protein
decreased blood flow and reduced supply
of nutrients and oxygen, leading to
Artery calcification
Impairment of muscle cells
decreased ATP generation in blood vessels
onset of heart failure
and heart muscle cells.
atherogenesis
In the case of familial hypercholesterolemia, the supply of nutrients, particularly
Figure 3. Presumed factors leading to atherogenesis and heart failure. See text
for detailed explanations.
fats, to peripheral tissues is restricted
AGE: Advanced glycation end-products; CHD: Coronary heart disease; LDL: Low-density
from early age, due to defective or defilipoprotein.
cient LDL receptors. This leads to
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doi: 10.1586/17512433.2015.1011125

Perspective

Okuyama, Langsjoen, Hamazaki et al.

Blood
marker

Mitochondrial
function

Muscle component

Glucose
tolerance test

Statin group/control group ratio

1.4

*
1.2

0.8

*
*

0.6

0.4

0.2

ns

Statins inhibit vitamin K2 synthesis

& accelerate artery calcification

Vitamin K1 (VK1), rich in vegetable oils

and vegetables, has one double bond at the
phythyl side chain. When ingested, its side
chain is cleaved to form VK3, after which
an isoprenyl residue with four double bonds
is inserted into VK3 to form VK2 (menaquinone-4) (FIGURE 7). The enzymes synthesizing
VK2 from VK1 are present in many tissues,
including the brain, and statins inhibit the
Figure 4. Comparison of skeletal muscle properties in the leg between statin
conversion of VK3 to VK2 by restricting the
users and statin non-users. As compared with non-users, statin users exhibited higher
supply of the isoprenyl intermediate. VKs
systolic blood pressure and elevated glycated hemoglobin (HbA1c) level. Levels of
serve as cofactors for an enzyme catalyzing
CoQ10, anti-peroxidative enzymes, uncoupling protein (UCP), Complex IV, and myosin
g-carboxylation of glutamyl residues in prowere lower, oxidative phosphorylation ability was lower and glucose level in glucose
teins such as coagulation factors, osteocalcin
tolerance test was higher [16].
*p < 0.05.
and matrix Gla protein. VK2 serves as the
AUC: Area under the curve; GSH: Glutathione; HC: Heavy chain; SBP: Systolic blood
cofactor in the carboxylation of matrix Gla
pressure; SOD: Superoxide dismutase.
protein present in bone, blood vessel,
lung, heart and kidney soft tissues. In
discussed later in this study. A recent example of the effect of sta- g-carboxylated form, the matrix Gla protein retains capacity to
bind calcium and protect blood vessels from calcification. Statins
tins on skeletal muscle has been evaluated (FIGURE 4) [16].
inhibit VK2 formation, and thereby accelerate coronary artery calciStatin administration & selenium deficiency cause heart fication, an important marker of the progress of atherosclerosis.
When VKs are used as cofactors, they are reactivated in tisfailure through a common mechanism
Selenium is an essential trace element, and is incorporated into sues. Therefore, VK deficiency is generally considered uncomselenoproteins using tRNAsc that is specific for selenocysteinyl- mon, except for the cases of long-term administration of
tRNAsc. A minor base of the tRNAsc, isopentenyl adenine, is warfarin as an anticoagulant. Chronic administration of warfasynthesized from a prenyl-intermediate, and its synthesis is rin is known to accelerate artery calcification [20]. Although not
inhibited by statins (FIGURE 5). In the Keshan province of China, directly related to statins, dihydro-VK1 produced during partial
dilated cardiomyopathy was common, which was later revealed hydrogenation of vegetable oils is not converted to VK2, and
to be due to selenium deficiency.
its administration leads to tissue VK2 deficiency [21], which
Selenoproteins include glutathione peroxidase, iodothyronine might be associated with atherogenesis.
deiodinase, thioredoxin reductases and more than 10 other
In a clinical study of diabetics, high-frequency statin users
kinds of selenoproteins. When glutathione peroxidase synthesis were shown to exhibit accelerated coronary artery calcification
is inhibited by statins, peroxidative stress is elevated, which is compared with low-frequency statin users [22]. Incredibly, the
generally accepted as causative for atherogenesis, carcinogenesis lead author chose to interpret this increase in coronary calcificaand aging. Statins also lower the levels of antiperoxidative tion in a positive light by speculating that: statins may lower
enzymes, such as superoxide dismutase and catalase, by the lipid-rich core of atherosclerotic plaques, and may enhance
unknown mechanisms (FIGURE 4).
the density of calcification as part of the healing process, potenIn accordance with the mechanisms described above, gluta- tially contributing to plaque stabilization and decreased cardiothione peroxidase activity in erythrocytes was shown clinically vascular disease events [23].
SH Mn se
pe -SO
ro
D
xid
as
e
Co U
C
m
O
p P
xid
M lex
at
yo
I
ive
sin V
O
ph
xid
H
os
C
at
ph
iv
or
(IC e p
yla
50 hos
tio
fo ph
n
r G or
lu yla
)
tio
G
n
lu
co
se
In
(
su AU
C
lin
(A )
UC
)

la

ta

Ca

Co

10

SB
P
Hb
A1
c

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1.6

to be inversely associated with CHD

events and positively with event-free survival when patients with CHD were followed up for 5.4 years (FIGURE 6) [17].
Although not directly related to the topic
of this article, selenoproteins are involved in
several steps of glucose metabolism and
insulin actions, providing a potential etiologic basis for statin-induced diabetes mellitus [18]. We presented an urgent proposal
that statins are contraindicated in patients
with diabetes mellitus [19].

doi: 10.1586/17512433.2015.1011125

Expert Rev. Clin. Pharmacol.

Statins
HMG-CoA prenyl-intermediates cholesterol

Isopentenyl adenine
Selenium-deficiency

Seryl-tRNAsc selenocysteinyl-tRNAsc

Se-containing proteins
Glutathione peroxidase : peroxidative stress atherogenesis, carcinogenesis, ageing
Thioredoxine reductase : supply of deoxyribonucleotide
Selenoprotein P (?) : insulin receptor processing
Selenoprotein

(?) : insulin signal transduction transport of GLUT4 to cell surface

Selenoprotein

(?) congestive cardiomyopathy (keshan disease)

Iodothyronine deionidase: T3 formation from T4 (thyroid hormone)

Figure 5. Statin administration and Selenium-deficiency cause heart failure

through a common mechanism. See text for detailed explanations.

Clinical trials showing or suggesting

that statins increased atherosclerotic
disease & heart failure

1.2

Japan Lipid Intervention Trial

This was the first large-scale intervention

trial with a statin performed in Japan, and
those with TC levels of 220 mg/dl were
treated with a low-dose simvastatin for
6 years with no control group [26]. The horizontal axis in FIGURE 8 is plotted with TC
levels after treatment. The mortality rates
for cardiovascular disease, cerebrovascular
disease, cancer and all causes were elevated
along with decreasing TC levels from
220 mg/dl. The higher mortality rates in
higher TC groups after treatment (FIGURE 8)
could be due to the fact that this population included 12-fold greater proportion of
familial hypercholesterolemia compared
with that of general populations (0.2%).
Although the authors of this report proposed to maintain TC levels below
240 mg/dl for the prevention of coronary
events, we emphasized the risk of lowering
TC levels below 220 mg/dl with statin [27].

1.0

1
p for trend, <0.001
0.9

0.8

0.6

0.8

0.4
p for trend, <0.001

0.2

0.7

0
<42.00

42.00
48.32

>56.31
>48.32
56.31
Erythrocyte peroxidase 1 activity, U/g hemoglobin

Figure 6. Relationship between red cell glutathione (GSH) peroxidase activity

and coronary artery disease (CAD) events. Patients with CAD (n = 636) were
grouped by erythrocyte GSH peroxidase activity, and coronary artery (CAD) events were
followed up for 5.4 years [17]. Event-free survival was determined at 5.4 years of
follow-up. Note the scale difference in the left and right ordinates.

A follow-up study on US veterans

with statins

US veterans diagnosed with heart failure were treated with statins for 5 years and compared with those without statin
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Perspective

Hazard ratio for event-free survival

Nakazato et al. evaluated coronary

computed tomography angiography in
2413 patients on statins and 4260 patients
not on statins. None of the subjects had
any known coronary artery disease. Statin
use was associated with a significant
increase in the prevalence and extent of
coronary plaques containing calcium [24].
In the case of end-stage kidney disease,
the level of proteins induced via VKabsence (PIVKA-II) was elevated, the
degree of carotid artery calcification was
elevated, and coronary artery mortality
and all-cause mortality were higher in
those with lower matrix Gla protein levels [25]. Besides g-carboxylation, VK2 is
known to regulate gene expressions
through the SXR receptor, and statins
adverse effects through this pathway are
expected to be revealed more extensively
in the near future.
Thus, statins can stimulate atherogenesis and heart failure through the suppression of prenyl-intermediates.

Hazard ratio for CAD events

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Statins stimulate atherosclerosis & heart failure

treatment (FIGURE 9) [28]. The authors of this report concluded

that veterans who were not exposed to statin therapy at any
time during the study period were 1.6-times more likely to suffer all-cause mortality. However, a critical problem is
doi: 10.1586/17512433.2015.1011125

Perspective

Okuyama, Langsjoen, Hamazaki et al.

inverse associations are often observed

between TC levels and all-cause mortalOsteoblast
Suppression
ity [2]. Therefore, the statin user group
should have characteristics leading to
Matrix
Gla
protein
uc-matrix Gla protein
Artery calcification
lower mortality at the start of the groupSoft tissue (bone, blood
ing, which is very likely to be reflected in
vessel, lung, heart, kidney)
the all-cause mortality shown in FIGURE 9.
Statins
-Carboxylation of Glu residue of proteins
It is essential in this kind of cohort study
to adjust background distribution of
X
V K1
V K2
V K3
Regulation of
TC levels.
gene expression
X
Incidence of diabetes mellitus was
(Cyp11aTaestosterone)
VK reactivation
greater
in the statin user group and
No
conversion
VK reactivation
X
appears
to
have increased along with the
Inhibition ?
X
Hydrogenation
period of statin use (FIGURE 9), which is
Phythyl side chain
Warfarin
of oils
consistent with the observations that staWarfarin
O
tins increase diabetes mellitus [18]. The
Dihydro-V K1
pharmacological mechanisms of statins
3
causing diabetes mellitus have been discussed in detail elsewhere [7].
O
Vitamin K1
More importantly, CHD mortality in
the statin-user group was higher and
Figure 7. Statins accelerate artery calcification. UC forms of osteocalcin and matrix
Gla protein are carboxylated at their glutamyl residues by a vitamin K-dependent
appears to have increased along with the
enzyme, and the carboxylated, activated form, for example, Matrix Gla protein binds
length of statin use when compared with
calcium to prevent artery calcification. See text for detailed explanations.
the statin nonuser group (FIGURE 9). Among
Gla: Carboxylated glutamyl residue (active form); Uc: Undercarboxylated (inactive form);
72
years of age in average, no positive or
VK: Vitamin K.
even inverse association of CHD mortality with TC is expected [29], and the proassociated with the statistics comparing statin users and statin portion of familial hypercholesterolemia is expected to be much
nonusers. When statin users and nonusers were grouped, the less than in general population. Hence, we interpret the
former group should have TC (or LDL-C) levels higher than results (FIGURE 9) that statins increased CHD mortality through
those in statin nonuser group. Particularly in aged group, mechanisms as described in previous sections of this article. At
least, we can point out that these results are not consistent
with those of clinical trials performed in 1990s, in which a relative risk reduction of approximately 30% in CHD events is
5
claimed (FIGURE 1, left).
Relative risks X mortality (%)

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uc-osteocalcin

Gla-osteocalcin

Bone hyperplasia

All causes
4

A large-scale follow-up study in Danes who were

diagnosed with cancer

3
2
1

Cancer
Stroke

0 CVD
<160 160 180 200 220 240 260 >280
Total cholesterol after simvastatin, mg/dl

Figure 8. Japan Lipid Intervention Trial with a low dose of

simvastatin. Those with total cholesterol (TC) levels of 220 mg/dl
were treated with simvastatin for 6 years (n = 41,801, 3570 years
of age) [26]. The abscissa is plotted with TC values after treatment.
In the ordinate plot, the risk values relative to that at 200 mg/dl
were multiplied by the mortality rate for each cause of death at this
basal point simply to visualize the weight of each cause of death.
This population included 12-fold greater proportion of familial
hypercholesterolemic subjects (see text for details).
CVD: Cardiovascular disease.

doi: 10.1586/17512433.2015.1011125

Danes at 40 years of age and diagnosed with cancer were followed up for 15 years, and statin users and statin nonusers
were compared [30]. In this large-scale, cohort study, the
authors concluded that the cancer mortality and all-cause mortality were lower in the statin user group (FIGURE 10). However,
the same criticism as described in the follow-up study on US
veterans (FIGURE 9) applies to this conclusion, that is, background
cholesterol levels need to be adjusted for between the groups of
statin users and nonusers before making any conclusions.
Similar to the case in US veterans (FIGURE 9), the mortality
from cardiovascular disease was higher in the statin user group
and tended to increase dose dependently. We interpret the
results to indicate that statins increased cardiovascular disease
mortality in this population by the mechanisms described earlier in this article, or at least we can point out that these results
are not consistent with those of clinical trials showing about a
30% decrease in CHD events (FIGURE 1, left).
Expert Rev. Clin. Pharmacol.

Statins stimulate atherosclerosis & heart failure

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Statin induced CoQ10 depletion & muscle damage

Statin adverse effects on skeletal muscle are the most commonly

reported statin side effects. Skeletal muscle weakness, muscle
pain and skeletal muscle cell death with elevated creatinine
kinase levels are a well-recognized phenomenon among prescribing physicians and patients alike. Statins have been demonstrated
to decrease the concentration of mitochondria in muscle, oxidative phosphorylation capacity and skeletal muscle mitochondrial
DNA levels [16,31,32]. In view of this obvious skeletal muscle toxicity, it would be nave to assume that statins would not likewise
negatively impact the much harder working heart muscle cells,
which have exceedingly high ATP requirements. Indeed, in animal data, statins have been shown to increase mortality in cardiomyopathic hamsters [33] and to increase ischemia/reperfusion
heart muscle damage in dogs [3436].
Evidence for a causative role for statins in human heart
failure

The first reported cases of statin-related heart failure were published in 1990 [37]. Five previously stable cardiomyopathic
patients had a dramatic deterioration in myocardial function
measurements and in clinical status shortly after beginning lovastatin. These patients returned to prestatin condition after
stopping their statin therapy and doubling their supplemental
CoQ10 from 100 to 200 mg/day.
In 2004, it was demonstrated that diastolic dysfunction developed in 10 of 14 healthy hyperlipidemic subjects after 36 months
of atorvastatin at 20 mg/day [38]. Impairment in the ATPdependent process of diastole is an early finding in congestive heart
failure. In this study, the early diastolic dysfunction was asymptomatic and reversed to normal after 3 months of supplemental
CoQ10 at 300 mg/day, while the patients continued to take their
statin therapy. In contrast to this mild asymptomatic impairment
in heart muscle function, in an ongoing study, patients who have
been on statin treatment for an average of 6 years presented with
overt and often permanent congestive heart failure.
In 2005, 50 consecutive patients presenting with severe statin
side effects were followed up for a mean of 28 months [39]. In
addition to symptoms of muscle pain and weakness, fatigue,
dyspnea, peripheral neuropathy and memory loss, roughly onefourth of these patients had evidence of congestive heart failure
at the time of presentation. All 50 patients had their statin
drug discontinued due to side effects and all were supplemented
with an average of 240 mg of CoQ10 per day and followed up
for 2 years. The patients chief complaints improved dramatically and 50% of those with heart failure showed significant
improvement in heart muscle function. There were no adverse
effects from statin drug discontinuation with no myocardial
infarctions or strokes and no side effects from CoQ10
supplementation.
In 2008, a study in 29 patients with coronary artery disease
found a significant increase in brain natriuretic peptide secondary to atorvastatin-induced plasma CoQ10 depletion [40] after a
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%
Incidence of disease or all-cause mortality

Clinical impact of statin-induced depletion &

supplementation of CoQ10

Perspective

80

CHD incidence

p < 0.001

60
Onset of DM

p < 0.001

40
All-cause mortality

p < 0.001

20
p = 0.004
Cancer incidence
0
(n = 3044)
Non-user

>025
2675
(n = 234) (n = 1086)

>75
(n = 6146)

User, period of use (%)

Figure 9. Effect of statins on the incidence of disease and

all-cause mortality in US veterans. Those diagnosed with
heart failure (n = 10,510, average age of 72 years, mainly male)
were treated with statins for 5 years, and were compared with
those without statin treatment (n = 3044) [28]. See text for our
critical interpretations.
CHD: Coronary heart disease; DM: Diabetes mellitus.

3-month treatment with atorvastatin. Brain natriuretic peptide

is a well-known marker for congestive heart failure.
Statin cardiomyopathy

Statin cardiomyopathy can be defined as an impairment in heart

muscle function consequent to statin drug therapy and not
explainable by any other underlying pathophysiology. Our current experience with statin cardiomyopathy indicates that it is
not at all uncommon, with 130 cases identified during a 4-year
period of time presenting to a solo cardiology practice. Although
the impairment in heart muscle function, secondary to statin
therapy, appears to be common after long-term (average 6 years)
statin drug therapy, it is clear that it is not being recognized. In
the words of Robertson Davies, The eyes see only what the
mind is prepared to comprehend. Physicians in general are not
aware that statins can cause heart failure and are clearly not recognizing it. Although vast majority of physicians readily recognize and diagnose heart failure in patients taking statins, the
heart failure is almost always attributed to other non-statinrelated factors, such as aging, hypertension and coronary artery
disease. Furthermore, it is difficult to recognize any adverse drug
effect when it is delayed by several years.
The mechanism for the impairment in heart muscle function
appears to be related to impaired mitochondrial function,
which in turn is related to statin depletion of CoQ10 [41], selenoproteins [4244] and heme A [45], all required for normal
mitochondrial function. Statin-induced impairment in heart
muscle function appears to be permanent, and even though
doi: 10.1586/17512433.2015.1011125

Perspective
1.4

Cardiovascular mortality p = 0.01

1.2

p = 0.08

Odds ratio

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Okuyama, Langsjoen, Hamazaki et al.

Cancer mortality*
*
*
* All-cause mortality

0.8
0.6

*
*

* , p < 0.001

0.4
0.2
0
0.010.75

0.761.50

>1.5

Defined daily dose X

Statin nonusers

Statin users

Figure 10. Effect of statin dose on mortality from cancer,

cardiovascular disease and all cause - A cohort study. Danes at
40 years of age were followed for 15 years (mean of 2.6 years) after
diagnosis with cancer in National Survey [30]. Although the values for
statin non-users were included in the statistics of the original report,
we did not connect the values from statin-user and nonuser groups
in this figure because possible difference in the background
cholesterol levels of the two groups had not been adjusted.
*p < 0.001 compared with statin nonusers in the original report.

patients may clinically benefit from discontinuation of the

statin along with supplemental CoQ10, we believe that many
years of statin drug therapy result in the gradual accumulation
of mitochondrial DNA damage. A prolonged decrease in mitochondrial CoQ10 would diminish the ability to protect mitochondrial DNA from free radical damage. After a critical
percentage of mitochondrial DNA is mutated, offspring mitochondria will progressively lose their efficiency to produce ATP
and simultaneously can generate more free radicals and result
in a self-perpetuating vicious cycle. The negative consequences
of statin-induced increase in coronary artery disease, coupled
with a direct statin toxicity upon the myocardium, can be
expected to be additive with enormous clinical implications.
With more than one million heart failure hospitalizations every
year in the USA [46], the rapidly increasing prevalence of
congestive heart failure is now described as an epidemic and it
is likely that statin drug therapy is a major contributing factor.
Statins other pleiotropic effects on heart disease

Persistent inflammation is considered a major risk factor for

atherosclerosis and heart failure. Statins are known to suppress
the prenylation of Rho protein and its downstream inflammatory cytokine production through NF-kB. Contrarily, statins
decrease LDL levels leading to increased entry of lipopolysaccharide into cells and increased inflammatory cytokine production. Thus, the effect of statins on inflammation is likely to
vary depending on the pathophysiological conditions.
Dolichol derived from prenyl-intermediates is essential for
glycoprotein and glycolipid biosynthesis, and its suppression by
doi: 10.1586/17512433.2015.1011125

statins would produce modified glycoproteins, for example,

unglycosylated insulin receptor. Although the relationship
between the statin suppression of dolichol synthesis and heart
disease is yet to be clarified in detail, inborn mutation in dolichol kinase has been shown to be associated with dilated cardiomyopathy [47,48]. A vasodilative molecule, nitric oxide (NO),
is synthesized in endothelial cells, and statins inhibit the activation (prenylation) of Rho protein to up-regulate endothelial
NO synthase and increase NO production [49]. On the other
hand, statins inhibit inducible NO synthase gene expression in
macrophages [50]. The impact of long-term endothelial NO
synthase activation and inducible NO synthase inhibition on
heart disease is not clear.
On the basis of these and other statin pleiotropic effects, statins seem to act as immune suppressive agents and may have
beneficial effects on those who have excessive and/or lifethreatening immune-inflammatory reactions, such as in transplantations [51]. However, immune suppression may be harmful
in those who have no immune/inflammatory disease.
Many observational studies of statins on heart failure, retrospective or prospective studies, have been performed, some of
which reported beneficial effects of statins on heart failure but
others did not, as reviewed by Bonsu et al. [52]. Intervention trials generally provide more reliable conclusions compared with
observational studies, and two large-scale, randomized controlled studies, GISSI-HF [53] and CORONA [54], reported no
significant beneficial effects of statins in heart failure. In clinical
fields, complex aspects of the etiology of heart failure (ischemic,
idiopathic and inflammatory causes) should be taken into
account rather than high cholesterol levels.
Expert commentary

Few cardiology specialists around the world have accepted that

there is no clinical evidence for the lower, the better hypothesis. The majority of clinicians still appear to accept the results
of meta-analysis of reports, including those published before
2004 when new penal regulations on the clinical trials came
into effect in the EU, that is, statins are effective in lowering
LDL-C levels and thereby preventing CHD incidence. Our
group and others [24] only adopt the conclusions of papers
reported after 2004 by scientists essentially free of conflict of
interest that statins are ineffective in preventing CHD. Severe
and often irreversible adverse effects of statins and their pharmacological mechanisms have been discussed in this study,
indicating that the applicability of statins should be severely
restricted. Clinicians should not rely on drug information provided by industry-funded trials, or should they trust study
abstracts of clinical publications, which frequently do not provide the full picture and present many deceptions. Nondrug
company-funded sources of information are likely to be much
more useful and less biased.
Five-year view

Pharmacological evidence and clinical trial results support the

interpretation that statins stimulate atherogenesis by suppressing
Expert Rev. Clin. Pharmacol.

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Statins stimulate atherosclerosis & heart failure

vitamin K2 synthesis and thereby enhancing artery calcification.

Statins cause heart failure by depleting the myocardium of
CoQ10, heme A and selenoproteins, thereby impairing mitochondrial ATP production. In summary, statins are not only
ineffective in preventing CHD events but instead are capable
of increasing CHD and heart failure.
Physicians who are involved in prescribing cholesterollowering medications cannot ignore the moral responsibility of
informed consent. Patients must be informed of all statin
adverse effects, including the ability to cause CHD and heart
failure, onset of diabetes mellitus, carcinogenicity, teratogenicity
and central and peripheral nervous disorders besides the wellknown rhabdomyolysis and hepatic injury. Most of these
adverse effects of statins become apparent after 6 or more years

Perspective

of statin therapy. Chronic administration could ultimately lead

to these statin adverse effects as pharmaceutical and biochemical research has now demonstrated.
Acknowledgements

The authors wish to thank JO Langsjoen, MD for his helpful advice in

preparing the manuscript.
Financial & competing interests disclosure

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 apart
from those disclosed. No writing assistance was utilized in the production
of this manuscript.

Key issues
.

Pharmacological and biochemical studies reveal the mechanisms of statins to stimulate atherogenesis and heart failure, and some
clinical studies support this interpretation.

Statins are contraindicated in diabetics as statin administration did not prevent diabetics from CHD (ASPEN [55] and 4D study [56]), and

Informed consent of statins should include increased coronary artery disease, heart failure, carcinogenicity, teratogenicity and central

statins worsen diabetic control [7]. Detailed mechanism of statin effects in diabetes has been published [7,19].
and peripheral nervous disorders besides the known adverse effects.
.

There have been several clinical papers published in which the abstracts are not consistent with the data in the text.

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