Aligning the 4Ms of Age‐Friendly Health Systems With Statin Use for Primary Prevention

Introduction: American College of Cardiology/American Heart Association (ACC/AHA) new cholesterol treatment guidelines recommend consideration of statin treatment for a larger proportion of population for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). It is important to assess the population impact of statin treatment under these new guidelines. Hypothesis: We assessed the hypothesis that increased statin use for the primary prevention of ASCVD might be accompanied by adverse effects among population. Methods: We used 2010 US Census, Multiple Cause Mortality, Third National Health and Nutrition Examination Survey Linked Mortality File (NHANES III 1988-2006, n=7095) and NHANES 2005-2010 (n=3178) participants 40-75 years of age to estimate prevalence of statin use, annual ASCVD deaths prevented and excess adverse effects by age, sex, and race/ethnicity if everyone followed updated guidelines. Results: Among 33.0 million adults aged 40-75 years meeting new guidelines for primary prevention of ASCVD (12.4 million with diabetes and 20.6 without diabetes but with a predicted 10-year ASCVD risk ≥7.5% and 70 ≤ low-density lipoprotein (LDL) ≤189 mg/dL), 26.9% (8.8 million) were on statins, indicating an additional 24.2 million potentially eligible for statin treatment (7.7 million with diabetes and 16.5 million without). Among the 7.7 million with diabetes, assuming 100% statin use, expected annual ASCVD deaths prevented were 2,514 (95% CI 592-4,142) and number-needed-to-treat (NNT) was 3,063 (1,860-13,017). The additional cases of myopathy based on estimates from randomized clinical trials (RCT) was 482 (0-2239) and number-needed-to-harm (NNH) was 15,992 (3,440-∞), and was 11,801 (9,251-14,916) and NNH 653 (516-833) based on estimates from population-based studies. Among 16.5 million without diabetes, ASCVD deaths prevented were 5,425 (1,276-8,935) with NNT 3,039 (1,845-12,914). The additional diabetes cases were 16,406 (4,922-26,250) with NNH 1,005 (628-3,349). Additional cases of myopathy was 1,030 (0-4,791) with NNH 15,996 3,441-∞) based on RCT estimates, and 24,302 (19,363-30,292) with NNH 678 (544-851) for population-based studies. ASCVD deaths prevented increased with age and >70% of ASCVD deaths prevented would occur among adults aged ≥60 years. Conclusions: Under ACC/AHA new guidelines for primary prevention of ASCVD by statin, assuming all those eligible took a statin, up to 12.6% of annual ASCVD deaths could be prevented, but could be accompanied by additional cases of diabetes and myopathy.

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Global variation of risk thresholds for initiating statins for primary prevention of cardiovascular disease: a benefit-harm balance modelling study

BMC Cardiovascular Disorders ◽

10.1186/s12872-020-01697-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Henock G. Yebyo ◽

Sofia Zappacosta ◽

Hélène E. Aschmann ◽

Sarah R. Haile ◽

Milo A. Puhan

Keyword(s):

Cardiovascular Disease ◽

Primary Prevention ◽

Assessment Method ◽

Competing Risk ◽

Net Benefit ◽

Cvd Risk ◽

Risk Threshold ◽

Risk Thresholds ◽

Statin Use ◽

Country Specific

Abstract Background We previously showed that the 10-year cardiovascular disease (CVD) risk threshold to initiate statins for primary prevention depends on the baseline CVD risk, age, sex, and the incidence of statin-related harm outcome and competing risk for non-CVD death. As these factors appear to vary across countries, we aimed in this study to determine country-specific thresholds and provide guidelines a quantitative benefit-harm assessment method for local adaptation. Methods For each of the 186 countries included, we replicated the benefit-harm balance analysis using an exponential model to determine the thresholds to initiate statin use for populations aged 40 to 75 years, with no history of CVD. The analyses took data inputs from a priori studies, including statin effect estimates (network meta-analysis), patient preferences (survey), and baseline incidence of harm outcomes and competing risk for non-CVD (global burden of disease study). We estimated the risk thresholds above which the benefits of statins were more likely to outweigh the harms using a stochastic approach to account for statistical uncertainty of the input parameters. Results The 5th and 95th percentiles of the 10-year risk thresholds above which the benefits of statins outweigh the harms across 186 countries ranged between 14 and 20% in men and 19–24% in women, depending on age (i.e., 90% of the country-specific thresholds were in the ranges stated). The median risk thresholds varied from 14 to 18.5% in men and 19 to 22% in women. The between-country variability of the thresholds was slightly attenuated when further adjusted for age resulting, for example, in a 5th and 95th percentiles of 14–16% for ages 40–44 years and 17–21% for ages 70–74 years in men. Some countries, especially the islands of the Western Pacific Region, had higher thresholds to achieve net benefit of statins at 25–36% 10-year CVD risks. Conclusions This extensive benefit-harm analysis modeling shows that a single CVD risk threshold, irrespective of age, sex and country, is not appropriate to initiate statin use globally. Instead, countries need to carefully determine thresholds, considering the national or subnational contexts, to optimize benefits of statins while minimizing related harms and economic burden.

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Comparison of Five Major Guidelines for Statin Use in Primary Prevention

Annals of Internal Medicine ◽

10.7326/l18-0181 ◽

2018 ◽

Vol 169 (1) ◽

pp. 66

Author(s):

Adrienne J. Lindblad ◽

Christina Korownyk

Keyword(s):

Primary Prevention ◽

Statin Use

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Statin use in older people primary prevention on cardiovascular disease: an updated systematic review and meta-analysis

10.37766/inplasy2021.12.0045 ◽

2021 ◽

Author(s):

Hao Huang ◽

◽

Hechen Zhu ◽

Ru Ya

Keyword(s):

Systematic Review ◽

Cardiovascular Disease ◽

Primary Prevention ◽

Older People ◽

Meta Analysis ◽

Statin Use

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Appropriate primary prevention of cardiovascular disease: does this mean more or less statin use?

Australian Prescriber ◽

10.18773/austprescr.2011.085 ◽

2011 ◽

Vol 34 (6) ◽

pp. 169-172 ◽

Cited By ~ 3

Author(s):

Jane Smith

Keyword(s):

Cardiovascular Disease ◽

Primary Prevention ◽

Prevention Of Cardiovascular Disease ◽

Statin Use

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Statin use and discontinuation in Danes age 70 and older: a nationwide drug utilisation study

Age and Ageing ◽

10.1093/ageing/afaa160 ◽

2020 ◽

Author(s):

Wade Thompson ◽

Dorte Ejg Jarbøl ◽

Jesper Bo Nielsen ◽

Peter Haastrup ◽

Anton Pottegård

Keyword(s):

Primary Prevention ◽

Older Persons ◽

Drug Utilisation ◽

Clinical Effects ◽

Discontinuation Rate ◽

Limited Evidence ◽

Factors Associated ◽

Drug Utilisation Study ◽

Statin Use

Abstract Background and objective There is limited evidence on the clinical effects of statins in older persons. We aimed to explore statin use and discontinuation patterns in Danes age 70 and older. Design Register-based drug utilisation study. Setting Danish nationwide health registries. Subjects All Danish persons aged ≥70 years between 2011 and 2016. Measurements (1) Monthly prevalence and (2) quarterly incidence of statin use, (3) characteristics of new users, (4) total amount of statin redeemed, (5) statin discontinuation rate between 2014 and 2016 in long-term statin users and (6) factors associated with discontinuation. Results We identified 395,279 unique older statin users between 2011 and 2016. The prevalence increased from 30% in 2011 to 33% in 2016 (23% for primary prevention and 56% for secondary prevention in 2016). The quarterly incidence fell from 11 per 1,000 persons in 2011 to 7 per 1,000 persons in 2016. The prevalence was generally stable in those 70 to 79 years. In those aged ≥80 years, the prevalence increased despite decreasing incidence. The proportion of persons initiating for primary prevention decreased from 58% in 2011 to 52% in 2016. Approximately 19% of long-term statin users discontinued therapy between 2014 and 2016. Increasing age was the strongest predictor of statin discontinuation. Conclusions Approximately one in three Danes age ≥ 70 years were taking statins in 2016. The characteristics of incident users shifted between 2011 and 2016, with less people age 80 and older starting on statins and fewer people starting for primary prevention.

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Abstract 17321: Guideline Recommended Statin Therapy Implementation and Cardiovascular Outcomes: Insights From a Multi-Site Healthcare Primary Prevention Cohort

Circulation ◽

10.1161/circ.142.suppl_3.17321 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Anum Saeed ◽

Jianhui Zhu ◽

Floyd W Thoma ◽

Oscar C MARROQUIN ◽

Aryan Aiyer ◽

...

Keyword(s):

Primary Prevention ◽

High Risk ◽

Statin Therapy ◽

Healthcare System ◽

Risk Groups ◽

Prescription Practices ◽

Ascvd Risk ◽

Mean Time ◽

Risk Categories ◽

Statin Use

Background: The 2013 and 2018 ACC/AHA cholesterol guidelines recommend using the 10-year ASCVD risk to guide statin therapy for primary prevention. Evidence of real-world consequences of non-adherence to these guidelines in primary prevention cohorts is limited. We investigated outcomes based on statin use in a large healthcare system, stratified by 10y ASCVD risk. Methods: Statin prescription practices in patients without CAD or ischemic stroke were evaluated ( 2013-2019). Patient categories constructed per the ASCVD risk were; Borderline (5%-7.4%), Intermediate (7.5%-19.9%) or High (≥20%). Guideline-directed statin intensity (GDSI) , at time of first event, was defined as; “none or any intensity” for borderline , “at least moderate” for Intermediate and high -risk groups. Mean (±SD) time to start/change to GD therapy from first interaction in healthcare, ASCVD incident rates [IR] and mortality were calculated across risk categories stratified by statin utilization. Results: Among 282,298 patients (mean age ~50y), 29,134 (10.3%), 63,299 (22.4%) and 26,687 (9.5%) were borderline, intermediate and high risk, respectively. Within intermediate-risk, 27,358 (43%) and 8,300 (31%) of high-risk never received any statin. Only 17,519 (65.6%) high-risk subjects who were prescribed statin, received GDSI [mean time ~1.8y]. A graded increase in ASCVD and mortality IRs was seen in all risk categories comparing statin versus no statin use (Table). Conclusions: In a multi-site healthcare network, over one-third of statin-eligible patients were not prescribed statin therapy. In eligible patients, who ultimately received statins, mean time to GDSI was ~2yrs. The consequences of non-adherence to guidelines is illustrated with greater incident ASCVD events and mortality among those patients not treated with statin therapy. Further research can define identify barriers and develop healthcare system strategies to optimize preventive therapies.

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