Statin Use in Primary Prevention of ASCVD According to 5 Guidelines

Study Questions:

Is there a difference in the sensitivity, specificity, and estimated number needed to treat (NNT10) with a statin to prevent one atherosclerotic cardiovascular disease (ASCVD) event in 10 years by criteria from five of the major guidelines?


A population-based contemporary cohort study was conducted in the Danish Copenhagen General Population Study in 45,750 individuals aged 40-75 years free of ASCVD at baseline. Enrollment was between 2003 and 2009, and data were analyzed between January 1, 2019, and August 4, 2019. Indicator was statin treatment according to the specific guideline criteria with assumption of a 25% relative reduction of ASCVD events per 38 mg/dl reduction in low-density lipoprotein cholesterol. The five guidelines included the 2018 US American College of Cardiology/American Heart Association (ACC/AHA), 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS), 2016 Canadian Cardiovascular Society (CCS), 2016 US Preventive Services Task Force (USPSTF), and the 2014 United Kingdom National Institute for Health and Care Excellence (NICE).


Median age at baseline examination was 56 years, and 43% of participants were men. During mean follow-up of 10.9 years, there were 4,156 ASCVD events. Overall, 44% were statin eligible with CCS, 42% with ACC/AHA, 40% with NICE, 31% with USPSTF, and 15% with ESC/EAS. Sensitivity and specificity for ASCVD events were 68% and 59% for CCS, 70% and 60% for ACC/AHA, 68% and 63% for NICE, 57% and 72% for USPSTF, and 24% and 86% for ESC/EAS. The NNT10 to prevent one ASCVD using moderate-intensity and high-intensity statin therapy, respectively, was 32 and 21 for CCS criteria, 30 and 20 for ACC/AHA criteria, 30 and 20 for NICE criteria, 27 and 18 for USPSTF criteria, and 29 and 20 for ESC/EAS criteria.


With similar NNT10 to prevent one event, the CCS, ACC/AHA, and NICE guidelines correctly assign statin therapy to many more of the individuals who later develop ASCVD compared with the USPSTF and ESC/EAS guidelines. The results therefore suggest that the CCS, ACC/AHA, or NICE guidelines may be preferred for primary prevention.


The findings apply to the Danish population, which is white European and high-income and probably lower risk than low-income other racial groups. It is not clear why the authors used the NICE QRISK2 2014 version, which was updated to NICE QRISK3 that provides the ability to use risk enhancers similar to the US ACC/AHA including treatment data, chronic kidney disease, and rheumatologic disorders. The US results were limited to those aged 40-79 years with Pooled Cohort Equations ≥7.5%. It would be interesting to know the results using the risk enhancers for those at borderline risk (≥5% to <7.5%). It is not surprising that the ESC/EAS guideline SCORE had much worse sensitivity and high specificity since its estimate is for CVD death at 10 years. Not surprisingly, the NNT10 was considerably lower with high-intensity statins.

Keywords: Atherosclerosis, Cardiovascular Diseases, Cholesterol, LDL, Dyslipidemias, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Practice Guidelines as Topic, Primary Prevention, Risk Factors

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