Review Looks at Statin Therapy Algorithm

A review published March 2 in the Journal of the American College of Cardiology discusses the ACC/American Heart Association (AHA) algorithm for the allocation of statin therapy in primary prevention, and proposes a hybrid approach to statin prescription.

According to the paper, the current algorithms for statin allocation in primary prevention use epidemiologic estimates of absolute risk – estimates that “do not ensure that those who benefit are selected for treatment.” The authors propose a “hybrid approach to statin prescription for apparently healthy men and women that strongly endorses pharmacologic treatment for those who have estimated 10-year risk ≥ 7.5 percent and for whom trial-based evidence supports statin efficacy in primary prevention.” They suggest that the ACC and AHA should recalibrate the current risk calculator to “avoid overestimation of 10-year risk and consider adding the simple ‘yes/no’ question concerning trial eligibility.”

While the authors acknowledge that such a strategy has not been subject to randomization, they suggest it would not be difficult to implement and has the potential to improve care by helping define patients that “clearly should be treated.”  

According to Neil Stone, MD, FACC, lead author of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, the proposal is interesting, but not clearly an improvement over the risk discussion currently recommended by the guidelines. He notes that so much of what is proposed by the review’s authors is already available to the clinician through the current guideline's clinician-patient risk discussion.

“The advantage of the current guidelines is the ability of the clinician to individualize the risk decision utilizing factors that improve net reclassification such as family history of premature atherosclerotic heart disease, hs-CRP ≥ 2.0 mg/L, coronary artery calcium (CAC) score ≥ 300, and ABI <0.9,” he said. “For young patients, additional factors recommended by the cholesterol panel were LDL-C≥ 160 mg/dl and excessive lifetime risk. All of these could inform the risk decision if the risk decision was uncertain. “

Stone also points out that the 7.5 percent or above guidepost was meant to begin the risk discussion, not to determine statin allocation. “The focal point for statin assignment in lower risk primary prevention in the 2013 ACC/AHA guidelines was the clinician-patient risk discussion. This is where other risk factors such as smoking and hypertension could be addressed, adherence to a heart heathy lifestyle emphasized and based on individual characteristics, a discussion of the potential for benefit with statin therapy compared to  the potential for adverse effects and drug-drug interaction.  Finally an informed patient preference was to be included in the discussion. This shared decision making was designed to prevent statin assignment to rely only on the risk estimation.”

Moving forward, Stone notes that continuing discussions of what factors are relevant to the clinician-patient risk discussion benefits us all. He also suggests that studies validating various approaches to risk assessment in primary prevention are clearly needed. “This commentary should stimulate further discussion,” he said.

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Hypertension, Smoking

Keywords: Algorithms, American Heart Association, Calcium, Cardiovascular Diseases, Cholesterol, Coronary Vessels, Drug Interactions, Heart Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Life Style, Patient Preference, Primary Prevention, Random Allocation, Risk, Risk Assessment, Risk Factors, Smoking, Uncertainty

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