Primary Prevention of Cardiovascular Disease (CVD) Events with Statins Alternate title: “Who should receive statins for primary prevention?”

Objectives Review recommendations for use of statins for primary prevention Use CVD risk and patient preferences to guide decision making about statins Answer questions about practical issues in risk- based primary prevention Note: Dr. Pignone is a former member of the US Preventive Services Task Force- the views expressed here are his and not necessarily those of the USPSTF. He has no additional disclosures to report.

Why is lipid screening and treatment important? Abnormal lipid levels increase the risk of cardiovascular events  Cardiovascular disease is the leading cause of morbidity and mortality in adults Treating abnormal lipid levels can prevent CVD events and premature deaths

Statins are effective for primary prevention Statins reduce CVD events by 25-30% 14% reduction in all-cause mortality Diet and exercise counseling have independent effects on CVD risk Cochrane Database Syst Rev. 2013 Jan 31;1:CD004816. doi: 10.1002/14651858.CD004816.pub5. Statins for the primary prevention of cardiovascular disease. Taylor F1, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S. Taylor et al Cochrane Review 2013

Statins reduce CHD events by 36%

Statins reduce all-cause mortality by 14%

2013 ACC/AHA recommendations Stone et al J Am Coll Cardiol. 2014;63(25 Pt B):2889-934.

2016 USPSTF guidelines

Our synthesis 10-year CVD risk < 5% No treatment (unless extreme LDL elevation: > 190 mg/dl) 5-10% Consider statin; Use shared decision making >10% Encourage statin use

Statins for primary prevention CVD risk reduction with statins proportional to LDL reduction No trials compare different “goal” lipid levels Use a moderate dose, generic statin High-dose statins may provide incremental benefit for higher risk primary prevention but also have additional harms Frequent monitoring of lipid levels during treatment is not beneficial

ACC-AHA global risk calculator

CVD risk output (and treatment recommendation)

Questions How should family history be incorporated into decision making about risk calculation? Should risk be re-calculated after initial treatment? Why use a higher risk threshold (10%) for recommending treatment?

How to incorporate family history into risk calculation? Family history of early myocardial infarction is a risk factor for future events Much of the effect of family history is mediated through traditional risk factors If a patient has a strong family history, it may be a reason to treat at more moderate risk levels (5-10%)

Re-calculation of risk Risk calculator is designed to be used before treatment with statins has been initiated Once treatment has been started, the estimation of future risk may be somewhat compromised, but is not too inaccurate If post-treatment risk remains high, ask whether the post-treatment lipid levels reflect the degree of reduction anticipated If not, check adherence and make sure dosage is appropriate; if reduction is appropriate, consider other risk factor reduction

Why use a 10% threshold for recommending treatment? Greater confidence that benefits >> downsides Corrects for possible over-estimation of risk with ASCVD risk calculator Emphasizes the importance of shared decision making – can help build adherence!

Conclusions Use risk factor information and risk calculator to guide treatment recommendations Prescribe moderate dose, generic statin for patients with 10 year CVD risk >10% Consider shared decision making for those at 5-10% risk

Other questions?