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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)

  • 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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