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GPs 'should prescribe statins to younger patients' using 30-year risk score

GPs should prescribe statins for primary prevention to 'younger, lower-risk' patients, according to a new study. 

Researchers compared the use of different risk prediction algorithms and found that using 30-year absolute risk reduction was the 'more optimal approach for determining statin eligibility', as it identified 'many additional low-risk individuals' with high long-term expected benefits of taking statins.

But GPs warned that changing from the current 10-year risk calculator would increase their workload, as they would have to carry out the 'bulk of prescribing and monitoring' and called for more evidence that such a change would be cost-effective. 

Researchers looked at a total of 1,688 patients, representing 56.6m US individuals, who were aged between 40 to 60 years old, from November 2017 to August 2018.

They selected patients who did not have cardiovascular disease, diabetes, or LDL-C levels greater than 190 mg/dL, and who were not taking statins.

The research team calculated 10-year risk of cardiovascular disease and 10-year and 30-year absolute risk reduction of cardiovascular disease for each individual, and found that the absolute risk reduction approaches were better able to avoid treatment of individuals with low expected benefit.

They noted that patients who met statin eligibility based on the 30-year absolute risk reduction threshold for treatment were younger (mean age 50 years) and more likely to be women than those recommended with a 10-year absolute risk reduction threshold.

The study, published in JAMA Cardiology, said: ‘A long-term benefit approach identifies younger, lower-risk individuals with high LDL-C levels for statin treatment and thus provides a more optimal approach for determining statin eligibility in primary prevention.’

'We demonstrate that using a 30-year benefit-based approach identifies many additional low-risk individuals with a high calculated benefit of long-term statin therapy, without extending treatment to individuals at low benefit,' it added.

But London-based GP Professor Azeem Majeed, head of primary care and public health at Imperial College London, warned that such a change would have a knock-on effect in general practice.

He explained: 'The way the current QRISK formula is used means that people who will be at high risk when they are older will not be placed on statins early in their life. Hence, there is some debate about switching to a lifetime risk rather than a 10-year risk of CVD.

'The limitation of changing current UK policy would be that many more people would become eligible for statins, thereby increasing NHS workload - particularly for general practices as they would be responsible for the bulk of prescribing and monitoring. Also, we would need more evidence that this would be a cost-effective use of NHS resources.'

NICE recently agreed to review recommendations for statins prescribing in over 75s for primary prevention, following new research which found that they did not effectively reduce the risk of heart attacks or stroke in older patients, unless they had diabetes and were also under 84 years old.

Another major study found 'no evidence' that lowering hypertension thresholds to treat low-risk patients with mild hypertension has any benefit.

Readers' comments (21)

  • Peter Swinyard

    So what is the NNT and NNH? These are the essentials we need so that we can adequately advise our patients. Statins are not beautiful, side-effect-free drugs. I have no problem in using for secondary prevention, but patients often choose not to take for primary prevention when given the statistics.

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  • Can we please stop this madness? Life is finite, there is no point clinging on by your fingernails, we all must die sometime. It’s quality that matters, not quantity.

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  • Or.... we could have a massive public health nationwide initiative to change eating habits to push a Mediterranean type diet, subsidise gyms and public exercise spaces, push for safe uptake of cycling etc. and continue to punitively tax unhealthy foods - all of which have far greater outcomes data than yet more medication in the form of statins for multiple health outcomes

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  • Why don't we just start statins at birth for all.....after all you can't be too careful.

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  • time to put it in the water ...

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  • Ivan Benett

    I would caution changing practice on the basis of this study. Far better to implement current risk and intervention recommendations from NICE than change. We already fail to estimate risk on 2/3 eligible people, and fail to prescribe in 2/3 of those at 10% 10 year risk.
    Obviously statins mandatory for secondary prevention unless good reason.

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  • Ivan Benett

    Why caution? We need to review in light of all new evidence. Also need cost-benefit assessment and cost per QALY. Need to wait for NICE review

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  • In 2000 the Journal of the American Medical Association published a study that showed a significantly greater CVD and CHD mortality risk and shorter life expectancy in young men with cholesterol levels of 6.21mmol/l or above compared with those whose cholesterol was 5.17 or less.
    Three large cohorts of men aged 18 to 39 were screened between 1959 and 1975. Those with a cholesterol of 6.21 or above had CHD mortality 2.15-3.63 times higher, CVD mortality 2.10-2.87 times higher and a life expectancy 3.8-8.7 years shorter.
    Seems sensible that young people with significantly raised cholesterols should at least be advised and offered treatment at a younger age rather than waiting until later when vascular damage has already developed.

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  • Ivan Benett

    Those demanding NNTs are right to do so, but risk confusing population based benefit with individual based risk management.
    So would I take a statin if I'm in a high risk group?
    Hell yes, if Chances of harm low and it doesn't cost me much.
    Leave population based considerations to commissioners

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  • National Hopeless Service

    I think society needs a grown up discussion about what medicine is trying to achieve. We all look after patients in the 80-90s who sit multimorbid & dementing in a chair in a residential home but good forbid if they should die of coronary artery disease or any other non-cancerous natural cause as that's a failure???

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  • Do you really think we can persuade millennials to take a tablet every night for the next 30 years on the off chance it might do some good. Totally agree with Doctor McDoctor Face. What are we actually trying to achieve.

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  • Vinci Ho

    One issue we have never really looked into seriously , is the so called nocebo effect of statin as reported previously i.e. the side effects are more likely to occur if patients have prior knowledge of them before commencing the drug.
    My feeling is these arguments on primary prevention with statin( excluding familial hyperlidaemia )have turned into a Brexit-like polarisation. Not sure whether we can have a common sense driven debate(s) anymore.

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  • Somewhere and somehow, somebody is making money.
    Wouldn't hold my breath for any 'expert' advice from NICE.
    Apart from their now expected lack of common sense, to be fair to them I wonder if NICE are even able to access ALL data from ALL clinical trials through MHRA yet?

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  • I can just see the next QoF coming out trying to screw us again over this. Blame the GP again. Make them send more letters, more blood tests, more results, more scripts. Sue them if the dose is wrong or they did not give "best care" providing the most powerful statins.

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  • It',s a calculation,it's not real,they didn't actually give patients statins for 30 years.

    This is more of a predictive meta analysis,like a medical complex financial product derivative,or as we say in general practice,fantasy.

    There is a vast meticulously researched anti statin literature,however I would suggest none has emphasised some of the key fallacies.

    When putting patients on statins particularly for 30 years the patient should be introduced to the importance of statin holidays.

    The key information,the NNT, is not on the data sheet

    There is a reason for that

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  • Next thing we know they will be trying to put it in the drinking water. Let's be clear; statins work, but not very well, and their cardiac effects are NOTHING to do with cholesterol, lowering of which is an epiphenomenon. And anyway - what actually is the absolute risk reduction they found? If it's

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  • Tom Robinson is so right. This would mean 30 year old taking statins for over 50 years! We have no conceivable idea what effect that might have.

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  • All the various arguments are sound but ‘flowers’ comment is the most realistic. It seems that if we don’t guarantee immortality to patients whatever their age or co-morbidities then we are not doing a good job or are unsafe and should be litigated accordingly. Can a bit of common sense be used sometimes. Isn’t that what true general practice is all about or has that all been put in the recycling bin now?

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  • I'm not going to do it. Statins don't work in primary prevention, in any clinically significant way, but they certainly cause side effects.

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  • Before commencing treatment, 'Ask yourself, should I treat or should I let the patient live?' That's what our Rector said to us when giving us our Degrees 30 years ago.
    I let them live.

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  • If you do phase 3 trials, you realize that all CRO and Clinical Monitors are under enormous pressure to get things done and to get the 'right data'. That might be the reason why some drugs slip through the loop and get registered as being effective while some important side effect profiles get hazy and omitted. The money per patient recruited can be anything from a few 100 to 5000 pounds per patient recruited according to the condition and the prospective price of the money. Launching a product can cost up to £500 million so the money has to come from somewhere.
    Is that why we keep coming under pressure from pseudo researchers to carry on increasing prescribing?

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