Physicians' Academy for Cardiovascular Education

More individuals eligible for primary prevention with statins in the 2019 ESC/EAS guidelines

2019 vs. 2016 ESC/EAS statin guidelines for primary prevention of atherosclerotic cardiovascular disease

Literature - Mortensen MB and Nordestgaard BG. - Eur Heart J. 2020;41(31):3005-3015. doi: 10.1093/eurheartj/ehaa150.

Introduction and methods

The 2016 ESC/EAS guidelines for management of dyslipidemia recommend the same treatment criteria as in previous guidelines, while other guidelines from the USA, Canada and the UK (ACC/AHA, USPSTF, CCS, NICE) recommend considerably lower treatment threshold for statin therapy. In addition, the 2016 ESC/EAS guidelines recommend class I/A statin therapy to individuals aged 40-65 years, while other guidelines advise statin therapy to those aged 40-75 years [1-5]. While these other guidelines targeted statin therapy to 31-44% of adults, the 2016 ESC/EAS guidelines only targeted 15% of adults. This leads to an estimated percentage of ASCVD events that could have been prevented by statin therapy for 10 years of 34% for ACC/AHA, 27% for USPSTF, 34% for CCS, and 32% for NICE compared to only 13% for ESC/EAS [6].

The 2019 ESC/EAS guidelines for primary prevention with statin use contain several important changes: 1) an updated Systemic Coronary Risk Evaluation (SCORE) risk assessment chart, also applicable to people older than 65, 2) eligibility was expanded with lower untreated LDL-cholesterol concentration eligible for class I/A statin therapy, and 3) class I/A recommendations for statin treatment is also provided for individuals aged 66-75 [7].

The current study compared the 2019 and 2016 guidelines for the management of dyslipidemias in regard to statin eligibility and potential impact on prevention in ASCVD in the general population using data from the Copenhagen General Population Study (CGPS).

The CGPS is an ongoing prospective cohort study of the Danish population that reflects the white general population in Copenhagen and surrounding area. For this study, individuals (n=45,750) aged 40-75 who enrolled between 2003 and 2009 and were free of ASCVD and statin use at baseline were included. Mean follow-up was 9.2 years. Age, sex, smoking, total cholesterol, and SBP were used to estimate the risk for ASCVD with the SCORE charts. The clinical performance of the 2019 and 2016 guidelines for ASCVD (fatal and non-fatal MI, stroke, and coronary death) were compared. The proportion of people eligible for statin treatment were calculated using the class I/A recommendations for primary prevention with statins for both guidelines and this study assessed which 2019 guideline change contributed to the increased eligibility for statin therapy. Also, sensitivity, specificity, positive predictive value and negative predictive value of the two guidelines were assessed. Lastly, the potential impact for ASCVD prevention over 10 years through full implementation of the guidelines was estimated.

Main results


Lower LDL-c threshold levels and class I/A recommendations for primary prevention with statin therapy to individuals aged 66-75 in the new 2019 ESC/EAS guidelines increased the number of individuals eligible for statin therapy and improved the potential impact for ASCVD prevention.


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