Physicians' Academy for Cardiovascular Education

Guideline differences regarding statin treatment affect ASCVD event prevention

Comparison of Five Major Guidelines for Statin Use in Primary Prevention in a Contemporary General Population

Literature - Mortensen MB and Nordestgaard BG. - Ann Intern Med 2018;168(2):85-92


Statin therapy is very important for the prevention of atherosclerotic cardiovascular disease (ASCVD), and currently, there are 5 major published guidelines with recommendations on how to use them:

Although all guidelines are based on the same evidence, they differ significantly in their recommendations. The impact of these differences in clinical practice is not known. This study evaluated the clinical performance of the 5 major statin therapy guidelines in 45,750 participants of the Copenhagen General Population Study (CGPS), an ongoing prospective cohort study of the Danish general population [6].

Eligible participants were 40-75 years old, had no ASCVD, were not on statins at baseline, and had a minimum of 5 years of follow-up. The potential effect of each guideline on ASCVD prevention in the general population during 10 years of follow-up, was assessed either with high-intensity statins (assuming a 50% LDL-c reduction) or with moderate-intensity statins (assuming a 30% LDL-c reduction), with a given 25% reduction in ASCVD events per 1 mmol/L (38.7 mg/dL) LDL-c reduction. ASCVD events were defined as non-fatal MI, fatal CHD, and stroke.

Main results


Statin eligibility differs substantially in the 5 major guidelines, and this impacts on the potential prevention of ASCVD events, which is a function of the number of eligible persons for statin therapy. Assuming negligible harm and low costs of statin therapy, the authors recommend to use the ACC/AHA or the CCS guidelines, rather than the ESC/EAS or USPSTF guidelines, in order to prevent more ASCVD events.

Editorial comment

In his editorial article [7], Mancini notes the complexity of developing medical guidelines and notes that differences in recommendations ‘….reflect the priorities, preferences, local needs, and practical realities of intended users.’ He mentions the limitations of the Mortensen et al study, which include the use of ASCVD end points other than those in the guidelines, the modeling of relative LDL-c reductions only, and the lack of examination of potential harm and cost of therapy, and he concludes: ‘Thus, although each organization must continue to evaluate the science in a fashion relevant to their priorities and the realities (including economics) of the settings in which their clinicians practice, Mortensen and Nordestgaard highlight how approaches liberalizing statin use for primary prevention and emphasizing large LDL-C reductions are expected to achieve greater reduction in ASCVD. They motivate us to examine whether the risk algorithms should be replaced by more sophisticated risk calculators or by the simpler approaches of randomized trials.’


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