USPSTF statin recommendations for primary prevention mostly unchanged since 2016
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The U.S. Preventive Services Task Force’s new recommendation statement on the use of statin therapy for primary prevention in adults aged 40 to 75 years with no history of CVD is similar to its 2016 recommendations.
The USPSTF continues to recommend statins for the primary prevention of CVD in patients aged 40 to 75 years with at least one CVD risk factor and 10% or greater 10-year risk for CVD.
The new recommendation, published in JAMA, is consistent with the 2016 USPSTF recommendation statement on statins for primary CVD prevention and is based on a review of 22 trials that reported on the benefits of statin use for primary prevention.
“Heart disease and stroke are the leading causes of death in the United States. The good news is that statins are a tool that can help prevent that first stroke or first heart attack for some people,” John B. Wong, MD, task force member and interim chief scientific officer, vice chair for academic affairs, chief of the Division of Clinical Decision Making, and a primary care clinician in the department of medicine at Tufts Medical Center, and a professor of medicine at Tufts University School of Medicine, told Healio. “Whether you should take a statin or not depends on three questions you should consider. One is your age, which should be between 40 to 75. Secondly, whether or not you have one or more risk factors. Then lastly, the chances of having that first stroke or first heart attack. Together, with your trusted health care professional, any adult in that age range could have a conversation with them and find out whether they're at high risk or increased risk. For those adults who are 76 and older ... we just don't have enough evidence to say whether adults at that age should or should not start a statin to prevent that first heart attack or first stroke.”
The key points are the same as in the draft recommendation statement issued in February.
Grade B: Recommended
For adults aged 40 to 75 years with one or more CVD risk factors such as dyslipidemia, diabetes, hypertension or smoking, and an estimated 10% or greater risk for 10-year CV event, a statin is recommended for primary prevention, the volunteer panel wrote.
Grade C: Depends on the patient’s situation
For adults aged 40 to 75 years who have one or more CV risk factors and an estimated 7.5% to 10% 10-year risk for a CV event, selective statin prescription for primary prevention is recommended. The odds of benefit from statin therapy in this population is less than in individuals with a 10% or more 10-year risk, the panel wrote.
“We classified adults at increased but not high risk as 7.5% to less than 10%,” Wong told Healio. “While the relative risk reduction is the same, the absolute benefit is greater for those who are at higher risk. So it was an easier decision to say at the population level, 10% or higher should be prescribed a statin. And those at 7.5% to less than 10% should have a conversation with their trusted health care professional to decide between the two of them, whether or not a statin would be right for them.”
I statement: Indeterminate harms and benefits
For adults aged 76 years and older, the USPSTF volunteer panel concluded there is insufficient evidence to establish a balance of benefit and harm of a statin for primary prevention.
“Now, we call for additional research. Some of the risk estimators not only predict 10-year risk for having a first stroke or heart attack, but some also predict lifetime risk for a certain age range,” Wong told Healio. “The most commonly used risk estimator is the Pooled Cohort Equation from the American College of Cardiology and the American Heart Association, and that starts at age 40. By age 60, it no longer predicts or estimates lifetime risk. So we're calling for additional research to understand whether or not a projection for 10 years or longer should influence decision making on the part of patients given that information. But as of now, we don't have that information.”
In a related editorial, Ann Marie Navar, MD, PhD, associate professor of internal medicine and population and data sciences at the University of Texas Southwestern Medical Center, and Eric D. Peterson, MD, MPH, Adelyn and Edmund M. Hoffman Distinguished Chair in Medical Science at UT Southwestern Medical Center, discussed potential issues with relying on 10-year estimated risk to guide statin prescription for primary prevention.
“Based on an understanding of the biology of atherosclerotic CVD, combined with the proven long-term safety and low costs of statins, it would be prudent to recommend a primary prevention intervention for adults with elevated LDL-C levels, who, because of this, are at increased lifetime risk of CVD, even if their 10-year risk does not exceed some arbitrary threshold,” Navar and Peterson wrote. “While using estimated 10-year CVD 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 CVD risk exceeds a certain arbitrary threshold before recommending a statin allows atherosclerosis to proceed unchecked for decades. 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 CVD prevention over a lifetime, not 10 years.”
For more information:
John B. Wong, MD, can be reached at jwong@tuftsmedicalcenter.org.
References:
- Chou R, et al. JAMA. 2022;doi:10.1001/jama.2022.12318.
- Navar AM, et al. JAMA. 2022;doi:10.1001/jama.2022.12982.
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