Statins for cardiovascular health: Latest guidelines, evidence

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Statins can reduce the risk of cardiovascular disease by lowering the level of low-density lipoprotein (LDL) cholesterol in the blood. clubfoto/Getty Images
  • Statins were first approved by the Food and Drug Administration (FDA) in 1987.
  • Updated guidelines from the US Preventive Services Task Force (USPSTF) suggest that statins benefit those aged 40 to 75 years with at least one risk factor for cardiovascular disease.
  • However, questions remain about who exactly can benefit from them.

Cardiovascular disease is the leading cause of death and disability globally, and there have been concerted efforts for decades to prevent and minimize its impact.

According to World Health Organizationwere 17.9 million deaths from cardiovascular diseases in 2019, representing 32% of all global deaths. Cardiovascular diseases are also a leading cause of premature death, causing 38% of deaths before the age of 70 years.

Lifestyle interventions are important for the prevention of cardiovascular disease, with smoking, obesity, diabetes, lack of physical exercise and excessive alcohol consumption all increasing the risk of developing cardiovascular disease. Statins are also an important pharmaceutical option for reducing cardiovascular disease in people at risk. It is estimated that more than 173 million people took statins in 2018.

Evidence published in the journal Lancet in 2010 shows that lowering low-density lipoprotein cholesterol by 1 mmol/L with statins reduces the risk of coronary heart disease and stroke by 24% to 25%.

Statins reduce the risk of cardiovascular disease by lowering the level of low-density lipoprotein (LDL) cholesterol in the blood. Too much LDL cholesterol can build up as “plaque” in your blood vessels and narrow their diameter. Over time this narrowing can block blood flow to certain organs. If blood flow to the heart is blocked, it can cause a heart attack, and if it occurs in the brain, it can cause an ischemic stroke.

Targeting the right patients with statins is key to getting the most benefit. The US Preventive Services Task Force (USPSTF) recently published its recommendation statement on the use of statins for the primary prevention of cardiovascular disease in adults in Journal of the American Medical Association (JAMA). The recommendations were slightly more conservative, but also very similar to existing recommendations from the American College of Cardiology (ACC) and the American Heart Association (AHA).

The new guideline was published after an evidence review that included 22 randomized clinical trials, including additional data from three randomized control trials that were not included in the last set of guidelines published in 2016. On the back of this , they have drawn three key recommendations for physicians dealing with patients.

They advised:

  • Statin use would provide moderate benefit for those ages 40–75 years with one or more factors that may increase the risk of cardiovascular disease, no history of cardiovascular disease, and an estimated 10-year risk of cardiovascular events of 10% or more.
  • Those of the same age with the same risk factors with a 10-year risk factor of cardiovascular events of 7.5% to 10% will have little net benefit from taking statins.
  • However, there was not enough evidence to determine whether it is beneficial to start statin use in those older than 75 years.

Dr. Edo Paz, cardiologist and VP of Medicine at K Health, said Medical News Today in an email:

β€œIn these updated guidelines, the USPSTF recommends that clinicians assess a patient’s risk of having a cardiovascular event (such as a heart attack or stroke) to decide which patients should be treated with statin therapy.

The ACC/AHA also provides additional guidance on the intensity of statin therapy, distinguishing between moderate- and high-intensity options. In general, the USPSTF guidelines are somewhat simpler, as they are directed at all primary care physicians, rather than cardiologists.

In the same week, a model was presented at the European Society of Cardiology Congress 2022 that echoed the review’s findings, supporting the use of statins in patients over 40 at high risk of cardiovascular disease.

The study created a model using data from 118,000 participants of the Cholesterol Treatment Trialists’ Collaborative and 500,000 individuals from the UK Biobank. It specifically looked at the difference between continuing statins for life, compared with stopping taking them at age 80, as there is little evidence of their value in people older than 75.

The main author Dr. Runguo Wu of Queen Mary University of London said: “Our study suggests that people who start taking statins in their 50s but stop at age 80 instead of continuing for life will lose 73% of the QALY benefit if they are at relatively low cardiovascular risk and 36% if they are at high cardiovascular risk – as those at high risk begin to benefit earlier.

“Women’s cardiovascular risk is generally lower than men’s. This means that for women, most of the lifelong benefits of statins occur later in life, and premature discontinuation of therapy is likely to be more harmful than for men.

Rather than suggesting that statin treatment was potentially controversial, clinicians should focus on areas where statin guidelines overlap, said Prof. Salim Virani, professor of cardiology at Baylor College of Medicine, Houston, TX, and one of the authors of the ACC/AHA. Guidelines for Primary Prevention from 2018.

In an editorial published by JAMA in the same issue as the USPSTF Recommendation Statement, Prof. Virani emphasized that the data review did not find “any significant harm associated with statin therapy” and called the recommendations “sensible and practical.”

In an interview with MNT, he explained that the main difference between these guidelines and the 2018 ACC/AHA guidelines was whether the threshold for introducing statins was for people with a 7.5% 10-year risk of cardiovascular disease, as is the case with the ACC/AHA guidelines, or 10% as is the case with the latest guidance from the US Preventive Services Task Force.

“Most patients whose 10-year risk is 10% or higher, well, they should be treated based on both guidelines,” said Prof. Virani. He added that further modeling of how many people these small differences would affect would be published in the coming weeks.

Prof. Virani explained that individual risk factors should be considered by clinicians and patients when considering whether or not to start statin treatment. While risk factors such as obesity and diabetes were considered in both sets of guidelines, the guidelines from the USPSTF did not mention Southeast Asian descent or pre-eclampsia, or the risks for postmenopausal women for example.

“Last but not least, the ACC/AHA guidelines have what we call these risk modifiers, which are factors that aren’t there when someone is doing the mandate risk calculation, but can be important for a patient, for example, a patient with a family. history of premature cardiovascular disease, these patients should be treated early, and the ACC/AHA guidelines also take these factors into account, which is the notion of the US Preventive Services Task Force recommendations.”

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