Long-term statins to prevent a first heart attack? Experts issue tips on making the decision

To statin or not to statin. That is the question addressed by leading cardiologists who say that "making the right choice hinges on the physician's clear explanation - and the patient's correct understanding" of the risks and benefits of long-term preventive use for people at high risk but yet to experience any heart attack or stroke.

The decision to take statins long-term needs to consider the balance of potential risks against reducing the chances of a future heart attack or stroke.

Statins are among the most widely used drugs in medicine, and the cholesterol-lowering agents have transformed the treatment of heart disease, which remains the number one culprit in USA death records.

They usually have a clear-cut role in secondary prevention for people who have already had heart attacks and strokes.

But the choice to use statins long-term for primary prevention is a "far trickier proposition for the tens of millions of Americans with high cholesterol but no overt disease," say the cardiologists behind a paper designed to help doctors and patients on the dilemma, published in the Journal of the American College of Cardiology.

The researchers at the Baltimore, MD, Johns Hopkins University School of Medicine, says that "to statin or not to statin" is one of the "most important questions faced by patients and physicians alike" so the JACC report offers "concrete tips" for clinicians on how to conduct this "vital discussion."

With a simple percentage risk of heart attack or stroke being possible to calculate from the guidelines issued to doctors on risk assessment, the report explains the importance of shared decision making in the risk discussion about statins between clinician and patient.

The risk score should not be used as a shortcut to expedite decisions. Instead, it should be a conversation starter, for the calculators that take values such as cholesterol levels and produce a likelihood of the patient having a heart attack or stroke at some point over the next 10 years of their life.

It is "tricky" to understand such a risk and make a decision about whether the benefits of statins, to reduce the chances of a heart attack, are worth the potential downsides of long-term use, including the rare possibility that muscle damage or diabetes can be precipitated by these drugs.

A decision 'right off the bat' is often not possible

It is such an important decision needing a careful balancing of individual risks and benefits that for many patients the discussion needs to be staged over the course of more than one visit to doctors.

"Each patient should be given the opportunity to make an informed decision that he or she is comfortable with. Some patients may be ready to make a decision right off the bat.

The discussion at the initial visit centers on examining the patient's 10-year estimated cardiovascular risk, the risk factors contributing to that risk, and therapeutic options, including lifestyle changes and statin therapy."

Asking what the patient already knows about statin therapy is important, and then the clinician can clarify or add additional information as relevant. It's about empowering the patient with the knowledge to make a decision."

However, "when a patient isn't ready to make a decision right off the bat," there are opportunities to break down the decision-making discussion over subsequent visits.

The 10-year risk calculator

For people under the age of 79 years who are not yet showing clinical signs of atherosclerotic cardiovascular disease (narrowing of arteries, which can include the coronary arteries, created by the formation of atherosclerotic plaques), doctors in the US may follow the risk assessment guidance jointly produced by the American College of Cardiology (ACC) and the American Heart Association (AHA).

A risk score developed for the 2013 guidelines is drawn from a number of factors, and a calculator tool returns this score when doctors plug in data from their patient. 

The official web page for the cardiovascular risk calculator includes a "launch web version" option along with buttons for app versions. It takes the following variables to return an individual risk score:

• Male/Female
• Age
• Race (white/African-American/other)
• Total cholesterol level
• HDL cholesterol level
• Systolic blood pressure reading
• Treatment for high blood pressure (yes/no)
• Diabetes (yes/no)
• Smoker (yes/no).

The score indicates the percentage chance of a heart attack or stroke within your lifetime and within the next 10 years, and conducting such a risk assessment, which requires accurate data from clinical testing, and careful interpretation, is recommended at different intervals depending on age.

Doctors should also use slightly different risk calculations when needed, because they differ by ethnicity - otherwise the calculator would overestimate the risk in, for example, Puerto Ricans, or underestimate the risk in Mexican-Americans.

The results give an indication of whether lifestyle adjustments and other preventive steps such as statins are needed to reduce cardiovascular risk.

A 10-year risk of 7.5% can be the starting point for lifelong statins

The authors of the cardiology advice discuss the recommendations found in those latest assessment guidelines from ACC/AHA, which lay down a starting point for seriously considering preventive action against cardiovascular risks.

The recommendations are that statins are considered as preventive therapy when the 10-year risk score for a heart attack or stroke is 7.5% or higher - "but they leave a lot of room for variation," say the cardiologists.

They explain that, for people with high cholesterol but no clinical heart disease, "the decision to start preventive statins - typically as a lifelong therapy - should factor in a patient's likelihood of suffering a heart attack or stroke over the next decade among several other variables."

"That decision should be informed by the intersection of scientific evidence, clinical judgement and patient preference, but clinicians need to individualize the advice."

Important drivers of heart risk conversations

If a patient has read a story that they feel is relevant to their case and could inform their decision making, then I would advise the patient to take the story with them to their next visit.

"They can ask the clinician the simple question: what does this mean for me?"

Questions about statins will persist for as long as they are so widely prescribed against the leading cause of death, and one study published in June 2014 brought clues about why statins increase diabetes risk.

The statins controversy is illustrated by one of the more recent news stories. A study published in January 2015 found that statins may not protect against Parkinson's, after all.

Specifically related to the guidelines discussed in the tips from the cardiologists, research has confirmed how influential these can be on levels of statin prescribing.

References:

Clinician-patient risk discussion, Seth Martin, et al., JACC, 2015, volume 65, number 13, pages 1,361-1,368, doi:10.1016/j.jacc.2015.01.043, abstract.