The diagnosis of high cholesterol, particularly elevated LDL or "lousy" cholesterol, in young, active individuals often leads to the recommendation of statins—a common prescription medication designed to lower cholesterol. This proactive approach is critical because elevated cholesterol levels are recognized as one of the most significant risk factors for heart attacks, strokes, and cardiovascular disease later in life. Dr. John Elefteriades, a leading heart surgeon, emphasizes that cholesterol levels from childhood are strong predictors of future cardiac events. Heart disease, notably, remains the leading cause of death for women, surpassing all forms of cancer combined.

Doctors typically recommend statins in two primary scenarios: for individuals who already have heart disease, or have experienced a heart attack or stroke; and, more commonly for younger patients, as a preventative measure against cardiovascular events when lifestyle modifications alone have proven insufficient. While an LDL level of 190 mg/dL or higher warrants immediate statin prescription, the decision is often more nuanced. Healthy cholesterol guidelines generally suggest total cholesterol under 200 mg/dL, LDL under 100 mg/dL, and HDL ("good") cholesterol at 60 mg/dL or higher. However, factors beyond just LDL numbers, such as family history, genetics, and other markers, play a crucial role. For instance, a family history of early heart attacks (before age 55 for fathers, or 65 for mothers) might lead to a statin recommendation even if cholesterol levels are merely "high" (160-189 mg/dL) or "borderline high" (130-159 mg/dL). For young individuals with total cholesterol over 200 mg/dL, concerns arise about inherited genetic mutations, which significantly increase heart disease risk. Cardiologist Dr. Christopher Kelly often performs genetic testing and prescribes medication if such a mutation is identified, affecting about 1 in 500 people. High levels of lipoprotein(a), or Lp(a), a specific fat, also heighten the risk of heart disease or stroke, prompting doctors to check this marker. Furthermore, a chest CT scan can reveal arterial plaque buildup, and starting statins at a young age can effectively prevent decades of further accumulation, according to Dr. Adedapo Iluyomade.

Despite some public apprehension, statins are considered low-risk medications. Dr. Iluyomade metaphorically describes them as "sheep in wolf's clothing." The decision to prescribe statins is less about age and more about an individual's ultimate risk of developing heart disease or experiencing a cardiovascular event. Dr. Kelly states that statins can reduce heart attack or stroke risk by 20 to 30 percent. Dr. Iluyomade also highlights that women are often under-prescribed statins due to delayed recognition of heart disease and insufficient representation in clinical trials, underscoring the importance of self-advocacy in healthcare decisions.

Currently, eight types of statins are available in the U.S., known for their safety and affordability. Dr. C. Noel Bairey Merz, director of the Barbra Streisand Women’s Heart Center, affirms their efficacy and safety for both men and women, based on extensive data. While generally safe, statins do carry small risks, including minor elevations in liver enzymes, an increased risk of diabetes (primarily in predisposed individuals), and muscle aches. Certain groups may experience side effects more readily, such as those who are immunosuppressed, transplant recipients, or on multiple medications, and studies suggest a slightly higher risk in people of Asian descent due to genetic factors. It's crucial for individuals who are pregnant, planning pregnancy, or breastfeeding to note that guidelines typically recommend avoiding statins unless absolutely necessary, despite the FDA removing the black box warning in 2021. This is especially important in later pregnancy stages when a developing fetus requires cholesterol, a point that necessitates discussion with a cardiologist for those with high genetic cholesterol or significant heart disease.

The rare and dangerous breakdown of muscle tissue known as rhabdomyolysis, often associated with statins, is exceedingly uncommon, affecting only one in 100,000 to one in a million people. Research published in The Lancet even found that statins were not the cause of muscle pain in over 90 percent of symptomatic individuals. Dr. Bairey Merz explains that some symptom reporting may be attributed to the "nocebo effect"—where anticipation of a problem leads to its experience, often amplified by social media. She also notes a cultural pushback against medications favoring "natural is better" narratives, but cautions that "in those good old days, mom had a stroke at 54." Dr. Kelly advises discussing concerns with a doctor, but stresses that the small side effects of statins often receive disproportionate attention compared to their invisible, life-saving benefits: "You don't know about the heart attacks or strokes you didn't have." Ultimately, the decision to start cholesterol medication should be driven by the individual's risk of not taking them, rather than their age.