Majority of statin-eligible US adults not taking a statin were never offered the therapy

Patient-Reported Reasons for Declining or Discontinuing Statin Therapy: Insights From the PALM Registry

Literature - Bradley CK, Wang TY, Li S et al. - J Am Heart Assoc. 2019;8

Introduction and methods

The 2013 ACC/AHA Guidelines broadened the statin recommendation, such that over 12 million high-risk adults in the United States were newly eligible for treatment with statins for primary CV prevention [1]. A large gap between guideline recommendations and actual clinical practice of statin use for both primary and secondary prevention has been described, even among the highest risk patients [2-4].

Statin underutilization results both from failure of clinicians to identify eligible patients and offer them statin therapy, and from patient refusal of the therapy when offered, or discontinuation by some patients. Understanding the reasons of each of these aspects can inform interventions to improve both primary and secondary ASCVD prevention.

This study is an analysis of the PALM (Patient and Provider Assessment of Lipid Management) registry, which aims to evaluate patient-reported reasons for not using statins (including not being offered the therapy, patient refusal and discontinuation of prior treatment), and differences in beliefs regarding safety and efficacy of statin therapy and perceived risk of ASCVD between current statin users and those were never offered, declined or discontinued treatment.

The PALM registry was a cross-sectional registry that enrolled 7938 patients from 140 cardiology, primary care, and endocrinology practices, who were potentially eligible for statin therapy. Information on statin use and beliefs regarding statin efficacy and safety were collected with surveys at baseline. Core lab lipid panels were also measured at baseline. Among those with survey and lab data, 5693 participants were eligible to start statins based on the 2013 ACC/AHA guidelines, 3184 because of prior ASCVD and 2509 had an indication for primary prevention statin use, based on their risk profile (mean age: 66 and 70 years, respectively).

Main results

  • 26.5% (n=1511) Of those eligible for statin therapy were not on treatment, 37.7% of those who were eligible for primary prevention and 17.8% of those recommended for secondary prevention.
  • Of the 1511 eligible patients not on treatment, 59.2% reported never having been offered a statin, 30.7% reported having taken a statin before, but discontinued therapy, and 10.1% had declined therapy after having been offered a statin.
  • Education levels and income levels were similar between current statin users, and those who discontinued or declined statins. Those who declined statins were more likely to have private insurance (67.3%) than current statin users (57.4%, P=0.02).
  • Compared with current statin users, those never offered a statin were more likely to be female, of black race, and of Hispanic ethnicity, and less likely to have prior ASCVD and to see a cardiologist, and they had lower rates of private insurance, college education and lower household incomes.
  • In 153 patients who declined statin therapy, fear of side effects was the reason most often cited (36.8%), followed by a preference to focus on diet or exercise (25.0%) and belief that statin therapy was unnecessary (19.4%). Primary prevention groups declined statins more often based on wanting to try diet and exercise, a dislike for taking medication or a preference for natural remedies, than did those eligible due to existing ASCVD.
  • More than half of those who reported discontinuing statin therapy, did so because of perceived side effects (55.0%), while 18.2% of adults felt they no longer needed it.
  • Those who discontinued statins were more likely to report worrying about heart attack or stroke compared with current users, while this did not differ between those declining and those using statins. Those who discontinued were less likely to agree that high cholesterol increases the risk of those two events than current users, and again this was similar between those who declined and current users.
  • More current users believed that statins are safe, as compared to those who declined or discontinued statin use. The differences were smaller when patients were asked about specific symptoms, and the belief that statins cause diabetes was similar in users and those who discontinued use.
  • In those who discontinued statin use, 21.3% were ‘possibly’ willing and 39.4% were ‘very likely’ or ‘almost certainly’ willing to retry a statin, as opposed to 29.1% who were unwilling.


This study showed demonstrates a large gap between recommendations of statin use and actual use. 27% Of adults who were eligible for statin therapy, did not receive the treatment. In almost 60%, this was because they were never offered a statin by their physician. A third of patients not using a statin, had done so before, but discontinued, and 10% declined use. In these groups, fear of side effects and perceived side effects were the most commonly reported reasons for not taking statins.


1. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med. 2014;370:1422–1431.

2. Maddox TM, Borden WB, Tang E, et al. Implications of the 2013ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol. 2014;64:2183–2192.

3. Pokharel Y, Tang F, Jones PG, et al. Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide. JAMA Cardiol. 2017;2:361–369.

4. Pokharel Y, Gosch K, Nambi V, et al. Practice-level variation in statin use among patients with diabetes: insights from the PINNACLE registry. J Am Coll Cardiol. 2016;68:1368–1369.

Find this article online at JAHA

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