Coronary Heart Disease and Statins Controversy (Last Part) – Blog Post by Asrar Qureshi

Dear Colleagues!  Today is Pharma Veterans Blog Post #183. Pharma Veterans shares the wealth of knowledge and wisdom of Veterans for the benefit of entire Pharma Community. It aims to recognize and celebrate the Pharma Industry Professionals. Pharma Veterans Blog is published by Asrar Qureshi on WordPress, the top blog site. If you wish to share your stories, ideas and thoughts, please email to asrar@asrarqureshi.com for publishing your contributions here.

Continued from Previous……

Current Recommendations for Statin Therapy

In the last 6 parts, I have walked you through the statins’ controversy, its basis, its protagonists and antagonists. There is no doubt that there are powerful voices on both sides of the disputes. There is equally no doubt that commercial interests are, at times, likely to prevail upon academic purity. It all relates to money, and there is a lot of money in statins. People can easily get killed where money prevails, be it guns, arms, drugs, or medicines. Fortunately, healthcare business has plenty of regulations and regulators. These either do not let it happens, or if it happens will gain control early.

 

Following recommendations for Statins’ are extracted from the authentic sources.

2018 American College of Cardiology (ACC/AHA) American Heart Association Multisociety Guideline on the Management of Blood Cholesterol¹

1. In all individuals, emphasize a heart-healthy lifestyle across the life course. 
2. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statins or maximally tolerated statins to decrease ASCVD risk. 
3. In very high-risk ASCVD, use an LDL-C threshold of 70 mg/dl (1.8 mmol/L) to consider addition of non-statins to statins.
4. In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dl [≥4.9 mmol/L]) without calculating 10-year ASCVD risk, begin high-intensity statin therapy. 
5. In patients 40 to 75 years of age with diabetes mellitus and an LDL-C level of ≥70 mg/dl, start moderate-intensity statins without calculating 10-year ASCVD risk.
6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy.
7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
8. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 5%-19.9%, risk-enhancing factors favor initiation of statin therapy.
9. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dl-89 mg/dl (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5%-19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.
10. Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.

US Preventive Services Task Force USPSTF 

·       Population	Recommendation	Grade (What's This?)
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater	The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. See the “Clinical Considerations” section for more information on lipids screening and the assessment of cardiovascular risk.	B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
Adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 7.5% to 10%	Although statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event risk of less than 10%, the likelihood of benefit is smaller, because of a lower probability of disease and uncertainty in individual risk prediction. Clinicians may choose to offer a low- to moderate-dose statin to certain adults without a history of CVD when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 7.5% to 10%.	C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
Adults 76 years and older with no history of CVD	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use for the primary prevention of CVD events and mortality in adults 76 years and older without a history of heart attack or stroke.	I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

References.

1.     https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/11/09/14/28/2018-guideline-on-management-of-blood-cholesterol

2.     https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/statin-use-in-adults-preventive-medication1

Concluded.