USPSTF Issues Guidance on Statin Use For Primary Prevention of CVD in Adults
The U.S. Preventive Services Task Force (USPSTF) on Nov. 13 released an updated recommendation statement regarding statin use for the primary prevention of cardiovascular disease in adults. The statement, published in the Journal of the American Medical Association, recommends using a low- to moderate-dose statin in adults aged 40 to 75 years without a history of cardiovascular disease who have one or more cardiovascular disease risk factors (dyslipidemia, diabetes, hypertension or smoking), and who have a calculated 10-year risk of a cardiovascular event of 10 percent or greater.
The USPSTF statement also recommends selective use of low- to moderate-dose statins in adults aged 40 to 75 years without a history of cardiovascular disease who have one or more cardiovascular risk factors and a calculated 10-year risk of a cardiovascular event of 7.5 percent to 10 percent. “Fewer persons in this population will benefit from the intervention,” according to the statement authors, “so the decision to initiate use of low- to moderate-dose statins should reflect shared decision making that weighs the potential benefits and harms, the uncertainty about risk prediction, and individual patient preferences, including the acceptability of long-term use of daily medication.”
The updated recommendation replaces an earlier recommendation from 2008 and is based on an extensive evidence review of 19 trials (n=71,344 participants) comparing statins vs. placebo or not statin. The evidence review found that adults at increased risk of cardiovascular diseases, but without prior cardiovascular events, had reduced risks of all-cause and cardiovascular mortality with statin therapy. Greater absolute benefits were seen in patients at greater baseline risk.
However, the USPSTF statement notes that not enough current evidence exists to assess the balance of benefits and harms of initiating statin use in adults aged 76 years and older. Additionally, the new recommendations do not pertain to adults with very high risk of cardiovascular disease, such as those with familial hypercholesterolemia or an LDL-C level greater than 190mg/dL. Instead, the USPSTF recommends that these patients be screened and treated in accordance with clinical judgment for the treatment of dyslipidemia.
In one of several editorial comments accompanying the USPSTF statement, Rita F. Redberg, MD, MSc, FACC, and Mitchell H. Katz, MD, note that “if physicians follow the task force recommendation and do not recommend treatment for primary prevention unless risk is greater than 10 percent in the presence of a risk factor, many patients would potentially avoid unnecessary treatment.” However, they also note that the “limitations of the evidence were not considered sufficiently.”
Ann Marie Navar, PhD, and Eric D. Peterson, MD, MPH, FACC, agree that questions still remain. “For patients in the gray area not covered by the guidelines, clinicians should be cautioned against adopting either a ‘treat none’ or a ‘treat all’ strategy,” they write. “Rather, gaps in the evidence provide opportunities for clinicians to practice the art of medicine and engage with patients in shared decision making regarding strategies for cardiovascular disease prevention.” Similarly, Philip Greenland, MD, FACC, and Robert O. Bonow, MD, MS, MACC, write that “clinical judgment and patient input are critical components of the decision process, especially for older patients and those at lower risk.”
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