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Cardiovascular disease (CVD) is the leading cause of mortality and is a major cause of morbidity around the world.1 HMG-CoA reductase inhibitors, also known as statins, are first-line therapy to optimize cholesterol levels and reduce risk of cardiovascular events. Patients with chronic liver disease such as nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), or hepatitis C tend to have a higher risk of CVD because these conditions are associated with the metabolic syndrome.2 Complications of the metabolic syndrome include dyslipidemia and insulin resistance, which are directly correlated with cardiovascular risk. With these factors taken into consideration, this patient population displays a clear indication for CV risk reduction therapy with a statin.3 Statin use in patients who are hepatically impaired raises concern to providers. The possible increase in aminotransferases enzymes may lead to worsening hepatic function.4 Tzefos and colleagues conducted a review to address the misconception of statin use being contraindicated in patients with active liver disease. The objective of this review was to investigate the safety and efficacy of statin use in these patients. 

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Chronic liver disease and elevated liver aminotransferases are commonly caused by NAFLD, which is a condition that involves steatosis in the liver not contributed to excessive alcohol consumption.3 NASH is an extreme type of NAFLD which is characterized by inflammation and damage to the liver that may lead to cirrhosis.5 This review included several studies that evaluated the safety of statin use in patients with active liver disease. Some studies, such as Rallidis et al. and Ekstedt et al., showed an improvement in patients' liver disease defined as a decrease in steatosis and the occurrence of fibrosis.4 There were also several studies with statin use showing improvement in certain biomarkers and pathways that play a role in NASH such as C-reactive protein, tumor necrosis factor-alpha, interleukin-6, adiponectin metabolism, and glyceraldehydes-derived advanced glycation end products.4 Tzefos et al. also included a post-hoc analysis of the GREACE study and found that patients with elevated aminotransferases on a statin had less cardiovascular events than those not on a statin (P<0.0001; number needed to treat = 15).4 When these same patients were then compared to statin users with normal aminotransferases, the patients with elevated liver enzymes benefited more from the statin therapy. The overall results from the 12 studies included in the review demonstrated improved lipid levels from statin use without any statin-induced adverse effects. In regards to liver aminotransferases, there was either normalization or even a reduction in these levels in patients taking a statin. 

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With 3.2 million people infected with hepatitis C virus (HCV) in the United States, it is a highly prevalent chronic blood borne infection.6 Evidence shows a possible association of increased risk of diabetes in patients with HCV, which indicates a need for therapy to decrease cardiovascular risk.7 Current evidence either shows statin therapy to have no effect in the patient's HCV disease state, or displays a benefit of statin use in patients ...

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