The U.S. Preventive Services Task Force now recommends adults ages 40 to 75 with no history of heart disease — but who nevertheless have at least one risk factor and an elevated risk of cardiovascular disease — take a low- to moderate-dose statin.
The independent panel of experts in prevention and evidence-based medicine issued the recommendation in the Nov. 15 issue of JAMA.
An estimated 505,000 adults died of coronary heart and cerebrovascular disease in 2011. The prevalence of heart disease increases with, ranging from about 7 percent in adults ages 45-64 to 20 percent in those 65 and older. It is somewhat higher in men than in women.
Douglas Owens, MD, was a member of the task force when the guideline was developed. He is a professor of medicine at the School of Medicine and director of the Center for Health Policy and Center for Primary Care and Outcomes Research. The centers are part of Stanford Health Policy. He is also a physician with the Veterans Affairs Palo Alto Health Care System.
We ask Owens some questions about the new guideline:
Q: What prompted this new recommendation by the task force?
Owens: Cardiovascular disease is the leading cause of death in the United States, accounting for 1 in 3 deaths among adults due to heart attack and stroke. And statins can provide an important benefit to people at elevated risk of cardiovascular disease. But in order to know whether statins are going to be beneficial, it’s important to know something about the patient’s cardiovascular risk.
We reviewed the literature comprehensively — including 19 randomized clinical trials involving more than 73,340 patients, as well as additional observational studies — to understand both the benefits and the harms of statins. We concluded that the benefits outweigh the harms in appropriate patients at increased risk of cardiovascular disease. The primary benefit of statins is a reduction in your chance of having a heart attack or stroke.
Q: What are statins and why do they offer such benefit?
Owens: A statin is a drug that reduces the production of cholesterol by the liver. High cholesterol is a significant risk factor for cardiovascular disease and stroke, and statins help prevent the formation of the so-called bad cholesterol. Statin drugs also help lower triglycerides, or blood fats, and raise the so-called good cholesterol, HDL.
While there are some reported side effects from the use of statins, such as muscle and joint aches, most people tolerate statins fairly well. There is mixed evidence about whether statins may result in a modest increase in the chance of diabetes, but the task force assessed the benefits to clearly outweigh harms in patients at increased risk of cardiovascular disease.
Q: Who should be taking low- to moderate-dose statins?
Owens: The task force recommends that clinicians offer statins to adults who are 40 to 75 years old and have at least one existing cardiovascular disease risk, such as diabetes, hypertension, high cholesterol or smoking. They also must have a calculated risk of 10 percent or more that they will experience a heart attack or stroke in the next decade.
The task force recommends clinicians use the American College of Cardiology/American Heart Association risk calculator to estimate cardiovascular risk because it provides gender- and race-specific estimates of heart disease and stroke.
For people with a risk of 7.5 to 10 percent of heart attack or stroke over the next decade, the task force recommends individual decision-making, as the benefits of statins are less in this age group because these people have a lower baseline risk of having a cardiovascular event.
The task force also looked at the initiation of statins in people 75 or older and found there wasn’t enough evidence to determine whether people in this age group who have not previously been on a statin would benefit from starting a statin. So the task force suggests people in this age group consult their physicians about whether a statin may be beneficial.
Q: Do these new statin guidelines override the task force recommendation in 2008 that adults be screened for lipid disorders due to high cholesterol?
Owens: Yes, this recommendation replaces the 2008 recommendation on screening for lipid disorders in adults.
The accumulating evidence on the role of statins in preventing heart disease has now led the task force to reframe its main clinical question from “Who should be screened for dyslipidemia?” to “Which population should be prescribed statin therapy?”
We recommend that physicians go beyond screening for elevated lipid levels and assess the overall cardiovascular risk to identify adults ages 40 to 75 years who will benefit most from statin use.
Q: What does the task force hope to accomplish with the new recommendation?
Owens: We hope this guideline will help both clinicians and patients decide what their cardiovascular risk is and what steps they can take to reduce those risks, which include a healthy lifestyle, a healthy diet and exercise, and for appropriate patients at elevated risk for cardiovascular disease, potentially a statin.
We also hope to highlight areas that would benefit from additional research. Further research on the long-term harms of statin therapy, and on the balance of benefits and harms of statin use in adults 76 years and older, would be helpful in informing clinicians and patients.