A Long-term Benefit Approach vs Standard Risk-Based Approaches for Statin Eligibility in Primary Prevention

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Journal Article 1 Mention

George Thanassoulis•2018

Allan D. SnidermanMichael Pencina

Top 15% · 85th percentile

37 citations · Surgery

Open Access

TLDR

Looking at how much statins can help over 30 years, instead of just 10, means more younger people who could benefit will get treatment and fewer people will get medicine they don't need.

Summary

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1 Study Aim

The study aims to compare a long-term (30-year) benefit-based approach to deciding who should get statins for preventing heart disease, versus the standard method that looks at 10-year risk. The authors want to see if using a longer time frame helps identify more people who would truly benefit from statin therapy, especially among younger adults. Simply put: The study wants to find out if looking further into the future helps doctors pick the right people for statin treatment.

2 Study Design

The researchers used data from the National Health and Nutrition Examination Survey (NHANES) collected between 2009 and 2014. They included 1,688 people aged 40 to 60 who did not have heart disease, diabetes, very high cholesterol, or were not already taking statins. For each person, they calculated the risk of heart disease over 10 years, as well as the expected benefit (absolute risk reduction) from statins over both 10 and 30 years. They then compared how many people would be recommended for statins using each approach. Simply put: The study looked at health data from thousands of middle-aged Americans to see who would get statins under different rules.

3 Findings

The study reveals that using a 30-year benefit-based approach would recommend statins to about 17.5% of people, compared to 9.5% using the standard 10-year risk method. This longer-term approach identifies more younger people and more women who have high cholesterol but lower short-term risk, meaning they would benefit from starting statins earlier. The 30-year method also prevents more heart disease events over time and avoids giving statins to people unlikely to benefit. The authors suggest that this approach could improve how doctors decide who should get statins for preventing heart disease. Simply put: Looking at long-term benefits helps more people who need statins get them and keeps people who don't need them from taking extra medicine.

Abstract

Importance: A 10-year benefit-based approach to statin therapy in primary prevention includes younger individuals with higher low-density lipoprotein cholesterol (LDL-C) and prevents more cardiovascular events than a risk-based approach. However, a 10-year treatment duration likely underestimates the expected benefits of statins. Objective: To model the impact of a 30-year benefit approach to select individuals for statin therapy. Design, Setting, and Participants: This cross-sectional analysis of the National Health and Nutrition Survey (NHANES) data set included samples of the US population from the 2009-2010, 2011-2012, and 2013-2014 data collection cycles. Individuals between 40 to 60 years old who did not have atherosclerotic cardiovascular disease, diabetes, or LDL-C levels greater than 190 mg/dL and who were not taking statins were included. Data analysis took place from November 2017 to August 2018. Exposures: We calculated 10-year risk of atherosclerotic cardiovascular disease and 10-year and 30-year absolute risk reduction (10-year ARR and 30-year ARR) of atherosclerotic cardiovascular disease for each individual. Main Outcomes and Measures: Number of individuals meeting eligibility for statins based on 10-year (atherosclerotic) cardiovascular disease risk, 10-year ARR, or 30-year ARR. Results: A total of 1688 individuals were included, representing 56.6 million US individuals. Statin eligibility based on 7.5% CVR10 was 9.5%; based on 2.3% 10-year ARR, 13.0%, and based on 15% 30-year ARR, 17.5%. The 10-year risk, 10-year benefit, and 30-year benefit approaches all led to similar acceptable mean absolute risk reductions at 30 years, with the benefit-based approaches better able to avoid treatment of individuals with low expected benefit. Individuals who met statin eligibility based solely on the 30-year ARR threshold of 15% or greater were younger (mean age, 50 [95% CI, 48-52] years) and more likely to be women (43% [95% CI, 26%-59%]) than those recommended with a 10-year ARR threshold of 2.3% or greater (mean age, 56 [95% CI, 54-57] years; 22% [95% CI, 10%-34%] women). This group also had lower 10-year risk (mean risk, 4.7% [95% CI, 4.4%-5.1%]) and higher LDL-C levels (mean level, 149 mg/dL [95% CI, 142-155 mg/dL]) than those recommended with a 10-year ARR threshold of 2.3% or greater (mean risk, 9.3% [95% CI, 8.3%-10.2%]; mean LDL-C levels, 110 [103-118] mg/dL). Preventable atherosclerotic cardiovascular disease events in 10 and 30 years were highest using the 30-year benefit approach (296 000 at 10 years and 2.03 million at 30 years) and lowest based on 10-year risk (204 000 at 10 years and 1.18 million at 30 years). Conclusions and Relevance: A long-term benefit approach to statin eligibility identifies nearly 1 in 6 individuals as having a high degree of expected long-term benefit of statins, with a number needed to treat of less than 7. This approach identifies younger individuals with higher LDL-C levels who would not be currently recommended for treatment and may provide a more optimal approach for determining statin eligibility in primary prevention.

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