The Statin Question

I have met variations of this patient many times. He is pushing 40. His BMI is under 25. He is not a smoker and does not have hypertension or diabetes. He sits across from me and looks worried. He hesitates before he asks, “Should I be on a statin? My dad had to have a CABG in his 60s, and I’m wondering if I should just start one now to protect myself?”

I have struggled with this question in an otherwise healthy patient. The Annals’ article “Finding the Balance Between Benefits and Harms When Using Statins for Primary Prevention of Cardiovascular Disease: A Modeling Study” (1) helps me find the answer. We often discuss in medicine that decisions are made on the basis of risks and benefits. The benefits of statins are well studied. The risks are well known too, but this article helps look at risks and benefits in a clearer picture. Age is a large contributor in determining if cardiovascular disease (CVD) risk is high enough to warrant a statin. On weighing risks and benefits, the article concludes that:

Higher 10-year risk thresholds for prescription of statins may be warranted than what current guidelines recommend and that the thresholds vary considerably by age, sex, and statin type. Guidelines emphasize benefits, and although harms are not ignored, they seem to have little effect on recommendations. The problem with such an approach is that eligibility for statins increases with age because more events can be prevented in elderly persons who are at higher CVD risk … our results suggest that guidelines should use higher 10-year risk thresholds when recommending statins for primary prevention of CVD and should consider different recommendations based on sex, age group, and statin type.

The article helps me realize that when during discussions of statins with patients, the benefits part is obvious but the risks part is often ignored. It is important to discuss risks. It is frustrating that the article does not mention family history or the most recent CVD calculator. A 2012 article in Annals entitled “Effect of Adding Systematic Family History Enquiry to Cardiovascular Disease Risk Assessment in Primary Care: A Matched-Pair, Cluster Randomized Trial” (2) shows that a patient’s family history can help identify risk factors for CVD. However, after identifying risk factors, what do you tell your patients?

This discussion is tailored to patients. A family history of CVD leads me to seek out other risk factors more clearly. Decisions on when and if statins should be started are patient dependent. For intermediate-risk patients with a strong family history, I may initiate statins. However, in my 30-something patient with no other known risk factors, I am now more likely to discuss benefits and risks of statins, whereas before the recent article in Annals, I may have glossed over risks.

References

1. Yebyo HG, Aschmann HE, Puhan MA. Finding the balance between benefits and harms when using statins for primary prevention of cardiovascular disease: a modeling study. Ann Intern Med. 2018 [Epub ahead of print] doi:10.7326/M18-1279
2. Qureshi N, Armstrong S, Dhiman P, Saukko P, Middlemass J, Evans PH, et al; ADDFAM (Added Value of Family History in CVD Risk Assessment) Study Group. Effect of adding systematic family history enquiry to cardiovascular disease risk assessment in primary care: a matched-pair, cluster randomized trial. Ann Intern Med. 2012;156:253-62. [PMID: 22351711] doi:10.7326/0003-4819-156-4-201202210-00002