Refining Statin Prescribing in Lower-Risk Individuals

Authors:
Pender A, Lloyd-Jones DM, Stone NJ, Greenland P.
Citation:
Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions. J Am Coll Cardiol 2016;68:1690-1697.

The following are key points to remember about this review on broader use of statin prescribing for low-risk asymptomatic patients:

  1. Recent guidelines, including those from the American College of Cardiology/American Heart Association (ACC/AHA), have recommended statin therapy in primary prevention for more adults compared with earlier guidelines.
  2. These guidelines recommend beginning with an assessment of risk prior to the initiation of statin therapy for most primary prevention patients. Absolute risk reduction estimates are useful for initiation of a discussion of cardiovascular disease (CVD) risk with patients. However, some population studies have observed that significant proportions of CVD events occur in adults who are considered low risk by current commonly used risk assessments.
  3. The ACC/AHA Pooled Cohort Equation has been observed to be accurate in some populations, but not in others. Cohorts with high socioeconomic status, healthy populations, may have low CV rates; thus, the Pooled Cohort Equation may overestimate risk in these cohorts. Despite the clinical utility of risk equations, the absolute individual risk of a patient may be difficult to determine by risk equation alone. Additional information such as coronary artery calcium (CAC) score may be helpful when deciding on statin initiation.
  4. Recent evidence suggests that some patients may benefit from statin therapy even when their risk is low (i.e., 4-5% 10-year risk). Information on CAC score may provide additional value. Additional testing other than CAC score may not be useful.
  5. Cost-effectiveness studies have observed cost-effectiveness for statin initiation even among adults with a 10-year risk below 7.5%. Middle age and those with one or more CV risk factor may be benefit groups in particular. However, anywhere from 5-29% of patients have been observed to report muscle symptoms. Clinicians should discuss evidence from trials such as the GAUSS-3 trial, which demonstrates that more than half of participants who report statin-related muscle symptoms also experience these symptoms while on placebo.

Clinical Topics: Diabetes and Cardiometabolic Disease, Clinical Topic Collection: Dyslipidemia, Noninvasive Imaging, Prevention, Nonstatins, Novel Agents, Statins

Keywords: Cardiovascular Diseases, Cost-Benefit Analysis, Diagnostic Imaging, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Middle Aged, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors


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