57% say 'no' to starting statins despite patient's 10.9% risk score

More than half of respondents chose to go against guideline recommendations for a hypothetical patient whose risk score made him a candidate for statin therapy in poll results published in the July 24 issue of the New England Journal of Medicine.

Joann M. Schulte, DO, MPH, an editorial fellow with the journal, and colleagues asked readers to consider treatment options under the guidelines published in late 2013 by the American Heart Association and the American College of Cardiology for reducing the risk of atherosclerotic cardiovascular disease. The guidelines set a 10-year risk threshold of 7.5 percent for considering initiation of statin therapy based on a new risk estimator; they also eliminated targets for low-density lipoprotein (LDL) levels.

The hypothetical patient was a 52-year-old male jogger who smoked and had a risk score of 10.9 percent. Respondents could choose between three options: not starting statin therapy; starting statin therapy and monitoring his LDL level; starting statin therapy and not monitoring his LDL level.

A total of 1,641 readers from 97 countries responded. Fifty-seven percent chose not starting statin therapy and another 26 percent responded they would start therapy and monitor his LDL level. The rest (17 percent) favored initiating therapy without monitoring LDL levels.

Readers outside the U.S. and Puerto Rico were more likely to not start statin treatment; 60 percent outside the U.S. and Puerto Rico chose the first option vs. 50 percent from the U.S. and Puerto Rico. Twenty-five percent of readers outside the U.S. and Puerto Rico favored statin therapy plus monitoring vs. 29 percent in the U.S. and Puerto Rico and 15 percent vs. 17 percent selected therapy without monitoring.

Of the 86 readers who commented, most recommended lifestyle modifications, particularly smoking cessation, although some also pointed out that it is hard to get patients to sustain lifestyle changes over time. Most proposed that statins should not substitute for lifestyle changes with lifelong benefits and mentioned that the guidelines emphasize a discussion with the patient before starting statin treatment.

“Many readers—from both the ‘treat’ and the ‘don’t treat’ camps—stated that management should be individualized, tailored to the likelihood of a particular patient’s adherence to a treatment regimen, whatever it may be, and based ultimately on the patient’s wishes,”  Schulte et al wrote.