Age, Gender and Drug Should Factor Into Statin Recommendation Interview with:

Prof. Dr. Milo Puhan Epidemiology, Biostatistics and Prevention Institute University of Zurich

Prof. Puhan

Prof. Dr. Milo Puhan
Epidemiology, Biostatistics and Prevention Institute
University of Zurich What is the background for this study? What are the main findings?

Response: The use of statins for primary cardiovascular prevention is controversial and there is a debate at what risks statins provide more benefits than harms.

Current guidelines recommend statins if the 10 year risk for cardiovascular events is above 7.5 to 10% and they do not distinguish between men and women, different age groups and different statins.

We found in our study that the benefits of statins exceeds the harms if the 10 year risk for cardiovascular events is above 14% for middle aged mean (40-44 years) but even higher for older age groups, and women.

In addition, the benefit harm balance varies substantially between different statins with atorvastatin providing the best benefit harm balance. What should readers take away from your report?

Response: There is no one size fits it all solution for statins (ie any statin with a single risk threshold for men and women and across age groups).  Age, sex and the type of statin need to be considered and it is likely the current recommendations, where more than 30% of the population above the age of 40 years are recommended to take statins, are associated with substantial overuse of statins. If the higher risk thresholds found in our study are considered and if prescription of statins is tailored according to age and sex, many millions of people would not take statins anymore . What recommendations do you have for future research as a result of this work? 

Response: The decision for or against statins does not depend only on the cardiovascular risk but also on patient preferences (e.g. how they value the prevention of heart attacks or strokes versus experiencing harms). Decision support tools (eg. decision aids) should be developed and tested in trials that explicitly consider the patient’s risk profile and preferences in order to see if such an individualized, preference sensitive decision making for statins for primary prevention is better than today’s decision making. Is there anything else you would like to add?

Response: The example of statins shows that in today’s recommendation there is much emphasis on benefits of statins and reliance on randomized trials only. This simplification of the decision making context may lead to unbalance recommendations. Harms and patient preferences need to be considered as well. Taking into account benefits, harms, outcomes risks and preferences requires modelling approaches such as ours that allow testing many different scenarios and developing more granulated and patient centered recommendations.


Benefits and Harms of Using Statins to Prevent Cardiovascular Disease. Ann Intern Med. [Epub ahead of print ] doi: 10.7326/P18-0019

Dec 4, 2018 @ 3:06 am


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