Although the 2013 American College of Cardiology and American Heart Association cholesterol guidelines expanded indications for statin use in heart patients, few primary care providers (PCPs) are prescribing more of the medication, researchers reported Jan. 25 in the Journal of the American Heart Association.
Lead author Jeffrey D. Clough, MD, MBA, and colleagues said the 2013 ACC/AHA guideline shift included “major” changes in nationally recommended approaches for preventing atherosclerotic cardiovascular disease.
“The ACC/AHA guidelines significantly expanded the population eligible for statin lipid-lowering therapy for primary prevention, mainly by emphasizing recommendations based on estimated cardiovascular risk and abandoning low-density lipoprotein cholesterol targets,” they wrote. “One study estimated that 12.8 million additional adults would be eligible for statin therapy compared with prior guidelines.”
But recent studies haven’t found a concurrent rise in statin prescriptions, the authors said. At best, evidence to date indicates a modest adoption of the new guidelines in clinical practice.
Clough et al. surveyed 72 primary care providers in a community-based North Carolina health network to evaluate the situation in 2017, comparing physicians’ opinions about statin therapy with the rate of statin initiation among their eligible patients between 2014 and 2015. None of the patients considered had ever received a prescription for the medication.
The authors said PCPs reported varying beliefs about the safety and efficacy surrounding primary care prevention with statins. Around 28 percent of PCPs said they believed statins caused diabetes, and just 16.7 percent reported discussing that risk with their patients. On the other hand, the vast majority (97.2 percent) of PCPs believed statins cause myopathy, and 72.3 percent said they always or often discuss that with their patients.
More than 77 percent of physicians said they use the 10-year ASCVD risk calculator in deciding whether or not to prescribe statins, but in 60 percent of cases other risk factors influenced prescriptions, and in 43 percent patient preferences were a factor.
“This study demonstrated that although primary care providers hold varying beliefs about the safety and efficacy of statins for primary prevention, these beliefs are minimally associated with statin prescription,” Clough and co-authors wrote. “Rates of statin prescription were low, and primary care providers report that a high proportion of patients are unwilling to initiate statin therapy despite their recommendation.”
Of 6,172 statin-eligible patients in the study group, just 22.3 percent received a prescription for a moderate- or high-intensity statin during follow-up, the team said. Providers who reported greater reliance on factors beyond ASCVD risk were less likely to prescribe the drugs.
Clough and colleagues said it appeared community-based PCPs did often accurately estimate the benefit of statin therapy in their patients, but personal beliefs and perceptions about adverse effects varied, and it’s unclear how productive patient-clinician discussions have been.
“The heterogeneity in clinician beliefs and approaches identified in our study suggests that patients are at risk for receiving different information and recommendations from different clinicians,” they wrote. “Approaches to help standardize these discussions to ensure that personalized decisions comport with patient preferences warrant further study.”