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Statin dose in primary prevention: aim for the target!
  1. Márcio S Bittencourt1,2,
  2. Fernando H Y Cesena3
  1. 1 Division of Internal Medicine, University Hospital, Sao Paulo, Sao Paulo, Brazil
  2. 2 Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  3. 3 Hospital Israelita Albert Einstein, São Paulo, Sao Paulo, Brazil
  1. Correspondence to Dr Márcio S Bittencourt, Division of Internal Medicine, University Hospital, Sao Paulo 2565, Brazil; msbittencourt{at}mail.harvard.edu

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Benefits from statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) are supported by high-quality evidence from randomised controlled trials (RCT). However, when and how to prescribe statins to individuals without ASCVD is a matter of debate. Strategies for initial management of low-density lipoprotein cholesterol (LDL-c) and goals of treatment differ among different guidelines (table 1).1–3 The National Institute for Health and Care Excellence (NICE) guidelines, for instance, recommend daily use of atorvastatin 20 mg in the primary care scenario when the estimated 10-year risk of ASCVD, as assessed by QRISK2, is at least 10%, whereas other guidelines propose different risk equations and different cut-offs. Also, the NICE document recommends clinicians to aim at lowering non-high-density lipoprotein cholesterol (non-HDL-c) by at least 40%,2 whereas other societies propose different eligibility criteria and different targets.

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Table 1

Recommendations for statin initiation in primary prevention of cardiovascular diseases and goals of treatment, according to different guidelines

An important step after a guideline publication is the assessment of its uptake among health practitioners and patients in the real world, as well as of the impact of its adherence on clinical outcomes. These analyses may not only verify its appropriateness, providing feedback for continuous improvement of recommendations but also identify targets to optimise delivery of health to the society.

In this context, a study by Akyea et al investigating whether a suboptimal LDL-c response to statins, based on the NICE guidelines, increases the risk of future ASCVD events. Using a large UK prospective cohort of subjects in primary prevention who were prescribed statins, the authors reported that those whose LDL-c lowered by <40% within 24 months (over half of the population study) …

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