If not deadly, a heart attack can be life-changing.

When the flow of oxygen-rich blood is suddenly stopped to a part of the heart muscle, a person’s mortality hangs in the balance. With heart disease ranking as the No. 1 cause of death, surviving a heart attack can shift a person’s perspective. Sometimes that can spur positive lifestyle changes, such as eating better or exercising.

But in other ways, life returns to normal.

And so while patients are routinely prescribed statins — cholesterol-lowering medications — to lower their risk of a second heart attack or another cardiac event like a stroke, research finds that many come off statins or take a less potent drug or dose than recommended. So called high-intensity statins — 40 to 80 milligrams of atorvastatin or 20 to 40 milligrams of rosuvastatin — are the current standard of care for individuals 75 and younger with coronary artery disease to lower “bad” or LDL cholesterol, as well as to reduce overall cardiovascular risk.

When you put a patient on a high-intensity statin you’re going to get a larger reduction in LDL cholesterol, explains Dr. Robert Rosenson, a professor of medicine at the Icahn School of Medicine at Mount Sinai in New York City, where he serves as director of cardiometabolic disorders. That’s a larger reduction in bad cholesterol compared to what you’d get taking a so-called intermediate or low-intensity statin, or a lower dose of statin. What’s more, statins offer protection — for instance, when taken to prevent a first heart attack — that goes beyond lowering cholesterol. The drugs reduce inflammation in the blood and the arteries; this can lower the likelihood of plaque — or build-up in the arteries made up of fat, cholesterol and other substances — rupturing and “allowing the blood to clot on that ruptured plaque and obstruct the artery resulting in irreversible heart damage,” Rosenson says.

[See: How to Avoid a Second Heart Attack.]

However, a study published online in the journal JAMA Cardiology in April underscored that many don’t continue taking statins as prescribed following a heart attack. Of studied Medicare patients ages 66 to 75 years hospitalized for a heart attack who filled a prescription for a high-intensity statin, less than half (about 42 percent) were still taking the drugs as initially prescribed, or with high adherence, two years following. More patients either weren’t taking high-intensity statins — and instead were on a less potent statin or a lower dose — or weren’t taking the drugs as often as recommended, and nearly one-fifth of patients (or about 19 percent) had stopped taking a statin.

“There’s very clear evidence that taking statins after a heart attack alters your outcome,” says Dr. Thomas Klevan, an interventional cardiologist and medical director of the cardiac service line at Sentara Healthcare, a health system based in Norfolk, Virginia. “It reduces mortality — the chance of dying — it reduces the chance of having a second heart attack, it reduces the chance of needing additional procedures like bypass surgery or stenting or angioplasty. It also reduces your risk of stroke.” American College of Cardiology/American Heart Association guidelines recommend patients 75 and younger with coronary heart disease take high-intensity statins.

The thing is, experts say, many people don’t take them as recommended — even when prescribed after a heart attack — because they feel back to normal. “Sometimes people get complacent after the LDL cholesterol falls and they stop the statin therapy,” Rosenson says. “Well, it’s going to go right back where it started, [and] they’re not accounting for the anti-inflammatory and the plaque-stabilizing effects of the statins.”

Though statins are among the most commonly prescribed drugs, clinicians say that they still have a perception problem: Many patients have concerns about side effects and are inclined to take less of the drug or not take them at all.

[See: 17 Ways Heart Health Varies in Women and Men.]

Between 5 and 15 percent of people can’t tolerate a statin due to muscle aches or pain, also called myalgia, and report that to the physician, says Dr. Peter Wilson, an endocrinologist who does preventive cardiology, and a professor of medicine at Emory University School of Medicine in Atlanta. That’s a common reason people seek to go off the drugs.

But experts say it’s important to work closely with a cardiologist or another doctor to determine if, in fact, the muscle aches and pain are likely due to the statin.

Though the research published in JAMA Cardiology didn’t analyze why patients stopped statins or didn’t continue taking them as originally prescribed, it did find that those patients who saw a cardiologist more frequently and those who participated in cardiac rehab were more likely to take high-intensity statins as recommended. If you have heart attack and you’re referred to cardiac rehabilitation, you have support that not only involves oversight of your exercise. “But you’re also getting a lot of secondary preventive therapy,” Rosenson says. “You’re getting education and guidance on your medications, such as your aspirin, beta blocker, ACE inhibitor and statin, and you’re getting education about the importance of those therapies over the long-term.”

What’s more a person who can’t tolerate one statin may do just fine on another — so it’s best to first switch to another drug in the class, says Dr. Timothy Henry, chief of cardiology at Cedars-Sinai Medical Center.

The most feared side effect from statin drugs — rhabdomyolysis, a muscle injury — is quite rare, Klevan says; around 3 of every 200,000 people taking statins develop the condition, according to Mayo Clinic. “It’s more than just muscle aching that the patient feels. It’s actual muscle tissue destruction. So when that happens, there’s damage to the muscle, there’s release of all of these proteins from the muscle into the bloodstream, and in some extreme forms it can cause kidney failure,” he says. “So that’s a life-threatening complication from statin drugs that occurs very, very, very rarely, but certainly would be an immediate reason to stop statins.”

If a patient tried multiple statin drugs and always experienced side effects they couldn’t tolerate, or if they had a history of rhabdomyolysis, Klevan says, it would be worth looking at alternatives to statins. Alternatives include a new class of drugs called PCSK9 inhibitors. These drugs have shown promise but haven’t been studied to anywhere near the degree of statins — since they’re newer. And they’re expensive, clinicians point out — not yet available in generic form like statins.

[See: The Facts on Heart Disease.]

Other statin side effects, too, which range from headache to drowsiness, difficulty sleeping and nausea, can be a deterrent to taking them for someone who may be asymptomatic otherwise. But the key, experts say, is to think about the potential long-term benefits, and work closely with a doctor to weigh those against any potential concerns — rather than making a unilateral decision regarding the drug therapy. “There’s overwhelming evidence that people who have [had] heart attacks in particular benefit from statins,” Henry reiterates, “and we need to do everything we can to improve adherence.”

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Why You Should Almost Certainly Stay on Statins After a Heart Attack originally appeared on usnews.com