Statin prescription in men and women at cardiovascular risk: to whom and when?

PURPOSE OF REVIEW: To review the recent evidence of the effectiveness of statin therapy in the primary prevention of cardiovascular disease in men and women without established cardiovascular disease (CVD). RECENT FINDINGS: The use of statins in patients without established CVD has important public health implications. Until recently, research has provided ambiguous answers and the reliability of treatment in older people (>65 years), women, and patients with diabetes has remained uncertain, mainly because of a lack of data or inconsistent findings within these clinically defined groups. The Justification for the use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) demonstrated a significant benefit of rosuvastatin in low-risk patients with no apparent vascular disease, low-density lipoprotein levels of less than 3.4 mmol/l, and elevated high sensitivity C-reactive protein. The latest meta-analysis of statins in 70 000 patients without established CVD confirmed the overall benefit of statins in these low-risk patients and found no significant heterogeneity of the treatment effect in the clinically defined subgroups of elderly (>65 years), women, and patients with diabetes. SUMMARY: The use of statins in low-risk patients without CVD remains a matter of intense debate, even following the latest findings from the JUPITER. Statins reduce cardiovascular risk and mortality in this patient category. However, the overall absolute risk reductions and cost-effectiveness of long-term statin prescription should be kept in mind before prescribing statins to relatively healthy individuals. The exact threshold of baseline risk of CVD has not been determined yet and is a challenge for emerging treatment guidelines in primary prevention.

[LDL cholesterol lowering therapy: no target value but personalised treatment]. / LDL-cholesterolverlagende therapie: geen streefwaarde maar behandeling op maat.

We previously recommended that LDL cholesterol lowering therapy be based on the risk for (recurrent) coronary events, rather than on arbitrary targets for serum LDL cholesterol concentration. We also recommended refraining from therapy with ezetimibe until its efficacy in preventing cardiovascular events had been documented. At the American Heart Association scientific sessions 2014 the results of the IMPROVE-IT study were reported. In this large, randomised trial, a modest benefit of the combination of simvastatin plus ezetimibe over simvastatin alone was reported after 7 years of treatment. The efficacy of such combination therapy was similar to the efficacy of high-dose statin therapy, while the combination therapy is much more expensive. Comparing the efficacy and costs of different preventive therapies, we recommend first prescribing aspirin and a moderate dose of statin, secondly an ACE inhibitor. A high-dose statin should be considered in high-risk patients. The combination of simvastatin and ezetimibe should be prescribed only in high-risk patients (e.g. diabetics after myocardial infarction) who do not tolerate high-dose statins.