A new way of determining heart disease risk could slash the numbers of people who are prescribed statins, suggests a recent study, although doctors warn that more information is needed and patients shouldn’t stop taking their medications.
Statins are used by millions of people as protection against high levels of LDL cholesterol, one of the causes of cardiovascular disease.
Doctors prescribe the daily pills based on 2013 guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC), which estimate risk based on age, diabetes, blood pressure and other factors, reports NBS News.
In the latest study, Dr Tim Anderson, an assistant professor of medicine at the University of Pittsburgh, and colleagues analysed the potential impact of a new heart disease risk calculator dubbed PREVENT, released by AHA last year, and compared estimates with older guidelines.
The data were from 3 785 adults aged 40 to 75, all of whom were participants in the National Health and Nutrition Examination Survey (NHANES).
The new calculator was developed to give a more accurate assessment of a person’s likelihood of developing heart disease by incorporating newly recognised risk factors like kidney disease and obesity.
The researchers found that among the participants, the 10-year risk of developing heart disease determined with the new tool was about half that estimated with the previous one, according to the report published in JAMA Internal Medicine.
Using PREVENT to calculate the 10-year risk for developing heart disease, the researchers determined that some 40% fewer people would have met the criteria for a statin prescription.
In other words, as many as 4m people in the US who currently take statins for primary prevention – meaning they have not had a cardiovascular event like a stroke or heart attack – may not need them, said Anderson, lead author of the study.
How is the new calculator different?
Among other factors:
• It removes race from the calculation, replacing it with a person’s residential code, which serves as an indicator of socio-economic status.
• Includes factors that can increase heart disease risk, such as kidney disease, obesity and a marker of poor blood sugar control (haemoglobin A1C).
• Calculates risk separately for men and women.
The latest findings are an opportunity for people who are taking statins for primary prevention to ask their doctor if they need to continue the medication, Anderson said.
While it’s important to treat heart disease risks before a first event, statins can cause side effects for some, including muscle pain, headaches, sleep problems and digestive problems.
“For patients who are right on the edge, they should know there are other things not captured by these calculators, like family history, so it’s very important to discuss this with their physician,” Anderson added.
However, some cardiovascular disease experts were concerned that the findings might convince some patients to stop taking their medications, especially considering many people already discontinue statins against their doctors’ advice.
The new risk calculator will need guidelines to go with it, said Dr Sadiya Khan, who was chair of the committee for PREVENT development and a professor of cardiovascular epidemiology at the Northwestern University Feinberg School of Medicine.
“Risk models don’t determine who is recommended to take statins: guidelines do,” she said. “I think the most important thing is the determination of when it will be recommended to initiate statins. That has not been decided yet.”
Dr Robert Rosenson, director of lipids and metabolism for the Mount Sinai Health System in New York City, warned that the small number of participants in the study wasn’t representative of the US population.
“Their main point, that fewer patients should be eligible for statins, is based on the limited numbers of people in the NHANES database,” he said. “That is alarming.”
And Dr Shaline Rao, director of heart failure services at the NYU Langone Hospital-Long Island, was concerned that patients who actually need anti-cholesterol drugs might take the wrong message.
“We see a lot of benefits of statins across many populations,” Rao said.
Study details
Atherosclerotic Cardiovascular Disease Risk Estimates Using the Predicting Risk of Cardiovascular Disease Events Equations
Timothy Anderson, Linnea Wilson, Jeremy Sussman.
Published in JAMA Internal Medicine on 10 June 2024
Abstract
Importance
In 2023, the American Heart Association (AHA) developed the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations to estimate 10-year risk of atherosclerotic cardiovascular disease (ASCVD), as an update to the 2013 pooled cohort equations (PCEs). The PREVENT equations were derived from contemporary cohorts and removed race and added variables for kidney function and statin use.
Objective
To compare national estimates of 10-year ASCVD risk using the PCEs and PREVENT equations and how these equations affect recommendations for primary prevention statin therapy.
Design, Setting, and Participants
This cross-sectional study included adults aged 40 to 75 years who participated in the National Health and Nutrition Examination Survey from 2017 to March 2020. Adults were defined as eligible for primary prevention statin use based on the 2019 AHA/American College of Cardiology guideline on the primary prevention of cardiovascular disease. Data were weighted to be nationally representative and were analysed from December 27, 2023, to January 31, 2024.
Main Outcomes and Measures
The 10-year ASCVD risk and eligibility for primary prevention statin therapy based on PREVENT and PCE calculations.
Results
In the weighted sample of 3785 US adults (mean [SD] age, 55.7 [9.7] years; 52.5% women) without known ASCVD, 20.7% reported current statin use. The mean estimated 10-year ASCVD risk was 8.0% (95% CI, 7.6%-8.4%) using the PCEs and 4.3% (95% CI, 4.1%-4.5%) using the PREVENT equations. Across all age, sex, and racial subgroups, compared with the PCEs, the mean estimated 10-year ASCVD risk was lower using the PREVENT equations, with the largest difference for Black adults (10.9% [95% CI, 10.1%-11.7%] vs 5.1% [95% CI 4.7%-5.4%]) and individuals aged 70 to 75 years (22.8% [95% CI, 21.6%-24.1%] vs 10.2% [95% CI, 9.6%-10.8%]). The use of the PREVENT equations instead of the PCEs could reduce the number of adults meeting criteria for primary prevention statin therapy from 45.4 million (95% CI, 40.3 million-50.4 million) to 28.3 million (95% CI, 25.2 million-31.4 million). In other words, 17.3 million (95% CI, 14.8 million-19.7 million) adults recommended statins based on the PCEs would no longer be recommended statins based on PREVENT equations, including 4.1 million (95% CI, 2.8 million-5.5 million) adults currently taking statins. Based on the PREVENT equations, 44.1% (95% CI, 38.6%-49.5%) of adults eligible for primary prevention statin therapy reported currently taking statins, equating to 15.8 million (95% CI, 13.4 million-18.2 million) individuals eligible for primary prevention statins who reported not taking statins.
Conclusions and Relevance
This cross-sectional study found that use of the PREVENT equations was associated with fewer US adults being eligible for primary prevention statin therapy; however, the majority of adults eligible for receiving such therapy based on PREVENT equations did not report statin use.
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