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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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