USPSTF Releases Updated Statin Guidelines For Primary Prevention of CVD

The U.S. Preventive Services Task Force (USPSTF) has released updated recommendations on the use of statins for primary prevention of cardiovascular-related events and mortality in adults 40 years of age or older without a history of known cardiovascular disease and/or who do not have signs or symptoms of heart disease. The new recommendations, published Aug. 23 in JAMA, are based on a review of new evidence assessing the benefits and harms of statin use since the publication of earlier USPSTF recommendations in 2016.

Highlights include a recommendation that clinicians prescribe a statin for the primary prevention of cardiovascular disease for adults ages 40 to 75 years who have one or more cardiovascular disease risk factors, such as dyslipidemia, diabetes, hypertension, or smoking, and an estimated 10-year cardiovascular disease risk of 10% or greater. The USPSTF also recommends that clinicians selectively offer a statin for the primary prevention of cardiovascular disease for adults (40-75 years) who have one or more cardiovascular disease risk factors and an estimated 10-year cardiovascular disease risk of 7.5% to less than 10%, despite a smaller likelihood of benefit in this group. Of note, the USPSTF suggests that current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of cardiovascular disease events and mortality in adults 76 years or older.

Overall, “in adults at increased cardiovascular disease risk but without prior cardiovascular disease events, statin therapy for primary prevention of cardiovascular disease was associated with reduced risk of all-cause mortality and cardiovascular disease events,” according Roger Chou, MD, et al., authors of the evidence report and systematic review. They write that the “benefits of statin therapy appear to be present across diverse demographic and clinical populations, with consistent relative benefits in groups defined by demographic and clinical characteristics.”

In a related editorial comment, Ann Marie Navar, MD, PhD, FACC, and Eric D. Peterson, MD, MPH, FACC, question whether the recommendations are “more of the same.” They write: “While using estimated 10-year cardiovascular disease risk may be helpful to guide patient-clinician shared decision-making, it should not continue to be the primary guide to identify statin candidates. Waiting for a person to reach an age when their 10-year predicted cardiovascular disease risk exceeds a certain arbitrary threshold before recommending a statin allows atherosclerosis to proceed unchecked for decades.” They go on to suggest that “it is time to realign statin guidelines with the biology of atherosclerosis by refocusing on the risk factor these medications treat, elevated LDL-C level, and considering cardiovascular disease prevention over a lifetime, not 10 years.”

In another editorial comment, Salim S. Virani, MD, PhD, FACC, highlights several issues identified in the USPSTF evidence review and recommendations that need to be addressed, including the low enrollment of women and some racial and ethnic groups, as well as individuals from outside the US, in most major statin clinical trials. He also points out ongoing “disparities in statin prescribing among women, members of racial and ethnic minority groups, and individuals from low socioeconomic strata.” He writes: “If clinicians want to reduce the rates of cardiovascular disease in the U.S., they will need to ensure that preventive therapies are prescribed to patients in an equitable manner and that receipt of preventive therapies is not dependent on an individual’s sex, race, ethnicity, income, or the zip code of their residence. This becomes even more important as the next few iterative waves of the COVID-19 pandemic are projected to have direct and indirect impacts on cardiovascular disease-related events in the years to come.”

Meanwhile, a third editorial published in JAMA Cardiology from Neil J. Stone, MD, FACC; Philip Greenland, MD, FACC; and Scott M. Grundy, MD, PhD, compares the differences between the USPSTF statin recommendations with the treatment algorithm for primary prevention included as part of the current 2018 American Heart Association (AHA)/ACC/Multisociety Blood Cholesterol Guideline. In an interview with CNN, ACC President Edward T. A. Fry, MD, FACC, called the USPSTF recommendations a “roadmap” and noted that they apply to broad groups or populations of patients, whereas ACC/AHA guidelines are designed to guide medical decision in a more individualized context.

Clinical Topics: COVID-19 Hub, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Hypertension, Smoking

Keywords: Smoking, Biology, Diabetes Mellitus, Hypertension, Socioeconomic Factors, Heart Diseases, Algorithms, Atherosclerosis, Cardiology, Dyslipidemias, Risk Factors, Primary Prevention, Minority Groups, Pandemics, COVID-19, Cardiovascular Diseases, Cholesterol, LDL, Hydroxymethylglutaryl-CoA Reductase Inhibitors, United States

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