GUIDING PRINCIPLES IN STATIN UTILIZATION: EMERGING CLINICAL AND PUBLIC HEALTH CHALLENGES
Charles H. Hennekens, M.D., Dr.P.H., Florida Atlantic University, Boca Raton, FL, USA
The current totality of evidence on statins in treatment and prevention of cardiovascular disease (CVD) includes 170,000 secondary prevention and high risk primary prevention patients. Those assigned at random to a statin had statistically significant and clinically important reductions in myocardial infarction of 30%, stroke of 15%, the need for stents and coronary artery bypass grafts of 25% and coronary death of 22%. In analyses of an additional 40,000 randomized patients assigned to more or less intensive statin therapy, more intensive therapy produced incremental clinical benefits on various manifestations of CVD. The results of more recent subgroup analyses among randomized subjects with 5-year risks lower than 10% were markedly consistent with those in secondary prevention and high risk primary prevention patients. This large and robust totality of evidence provides clinicians with challenges and opportunities to more widely prescribe statins in treatment and prevention of CVD. In secondary prevention and high risk primary prevention, the challenge is to more widely prescribe statins as the first line drug of choice. In low risk primary prevention subjects previously considered ineligible, the available totality of evidence provides clinicians the opportunity to expand statin utilization. The more widespread and appropriate utilization of statins, as adjuncts, not alternatives to therapeutic lifestyle changes (TLCs), will yield net benefits even in low risk primary prevention subjects unwilling or unable to adopt TLCs. The decision to prescribe statins should be an individual clinical judgment that includes all the risk factors of the patient, not just those in any risk algorithm. Finally, following these guiding principles will lead to greater and more appropriate utilization of statins. This, in turn, will lead to greater net clinical and public health benefits in the treatment and prevention of CVD.