At last we have a reasonable explanation why statins can cause some people to suffer skeletal muscle pain and damage, but do not cause heart muscle damage (JACC: Basic to Translational Science, Aug 2019;4(4):509-523). Muscles contract after they release calcium from their cells. However, statins cause muscles to leak calcium from their cells. The muscles of some people can tolerate these irregular leaks of calcium, but for others, the statin-caused calcium leaks interfere with normal muscle contractions to cause pain. This brilliant study, done with both humans and rats, shows that:
• The muscles of most people are not harmed by the calcium leak, but some people are either genetically or environmentally susceptible to statin-induced muscle damage.
• A regular moderate exercise program may help some people prevent the muscle changes that cause calcium leaks.
• Very intense exercise can cause some people on statins to develop muscle damage by damaging calcium gatekeeper proteins. The authors found that 70 percent of highly-competitive athletes developed severe muscle damage when they exercised at near-maximum effort.
• Statins do not cause calcium leakage in heart muscles because calcium movement during heart muscle contractions is regulated by different gatekeeper proteins, and therefore statins do not cause heart muscle damage or irregular heartbeats.

Interestingly, in the rats, the researchers observed that:
• statins did not affect muscle function or strength,
• exercise corrected the muscle changes in the rats who had free access to exercise wheels, and
• the exercising rats treated with statins were able to run twice as far as rats not given statins.

How Statins May Damage Skeletal Muscles
Statins lower inflammation and the bad LDL cholesterol that increases heart attack risk, but LDL is necessary to form cell membranes, so statins may increase muscle damage normally caused by intense exercise. Statins can raise blood sugar and triglycerides and lower the good HDL to increase risk for diabetes (J of Clinical Lipidology, July-August 2016;10(4):1022-1029), and the people most likely to suffer muscle pains when they take statins are those with pre-diabetes or diabetes who have high rises in blood sugar after meals (Brit Med J. Open Diabetes Research & Care, Oct 23, 2017). Another recent study showed that statins interfere with the ability to exercise and to compete in sports, even in patients who report no symptoms (J Clin Endocrinol Metab, 2018;103(1):75-84). See Statin Drugs and Exercise

My Recommendations
Today statins remain the major choice of heart-attack preventing drugs (J Am Coll Cardiol, 2014;63(25 pt B):2889-2934), but lifestyle changes can be equally effective. Statins do lower cholesterol and inflammation to help prevent heart attacks. If your LDL cholesterol is above 100 or you have other factors that increase risk for a heart attack, most guidelines recommend that you take statin drugs to help protect you from suffering a heart attack. However, statin drugs come at a price. They can make your muscles hurt and interfere with your ability to exercise. If you are a competitive athlete, they can interfere with your ability to compete at your best.

Lifestyle changes can be as effective as statins in lowering high blood levels of LDL cholesterol and reducing your risk for a heart attack. Whether or not you and your doctor decide that you should take statins, I recommend that you:
• avoid being overweight
• try to exercise every day
• avoid smoking
• avoid or restrict alcohol
• avoid sugar-added foods, all sugared drinks including fruit juices, red meat, processed meats, and fried foods
• eat plenty of vegetables, fruit, nuts, beans, whole grains and other seeds
• keep blood levels of hydroxy Vitamin D above 20 nmol/L
Heart Attack Prevention Guidelines
Statins, Low Vitamin D and Muscle Pain