AIM: Coronary disease risk, not cholesterol, should drive statin use

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A strategy of tailoring statin therapy based on patients' overall risk of coronary artery disease (CAD) events compared with a strategy of targeting cholesterol levels resulted in fewer cardiac events while treating fewer persons with high-dose statin therapy, according to a study published Jan. 19 in the Annals of Internal Medicine (AIM).

Although treating to lipid targets (treat to target) is widely recommended for CAD prevention, according to the authors, some physicians have advocated administering fixed doses of statins based on a person's estimated net benefit (tailored treatment).

Rodney A. Hayward, MD, director of the Veterans Affairs Center for Health Services Research and Development and a professor of internal medicine at the University of Michigan Medical School in Ann Arbor, Mich., and colleagues sought to examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.

“We’ve been worrying too much about people’s cholesterol level and not enough about their overall risk of heart disease,” said Hayward.

In the study, researchers evaluated data from statin trials that included Americans ages 30-75 with no history of heart attack. Using a simulated model, they assessed the benefit of five years of treatment that was tailored, on CAD risk factors such as age, family history, diabetes, high blood pressure, smoking status and, recently, C-reactive protein.

Compared with the standard National Cholesterol Education Program (NCEP) III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more quality-adjusted life-years (QALYs) over five years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins, the authors reported.

“The bottom line message – knowing your overall heart attack risk is more important than knowing your cholesterol level,” Hayward said.

“If your overall risk is elevated, you should probably be on a statin regardless of what your cholesterol is and if your risk is very high, you should probably be on a high dose of statin,” the authors wrote.

“However, if your LDL cholesterol is high, but your overall cardiac risk is low, taking a statin does not make sense for you,” Hayward said. “If your cholesterol is your only risk factor and you’re younger, you should work on diet and exercise.”

The researchers acknowledged, as a limitation, that the model assumptions were based on available clinical data, which included few persons 75 years or older.

Based on the sensitivity analysis, the investigators said that no circumstances were found in which a treat-to-target approach was preferable to tailored treatment.

Hayward and colleagues found that tailoring treatment to a patient’s overall heart attack risk by considering all their risk factors was more effective and used fewer high-dose statins than current strategies to drive down cholesterol to a certain target. They wrote that their “results were robust, even with assumptions favoring a treat-to-target approach.”

The Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative provided the primary source of funding for the study.