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Latest statins guidance keeps more conservative approach to preventing first stroke or heart attack

The recommendations are a little more conservative than guidelines put out by the American College of Cardiology and the American Heart Association, and some doctors wonder if they should be more aggressive.

Specifically, the USPSTF guidance published Tuesday in JAMA recommends statins for adults ages 40 to 75 who have one or more risk factors of cardiovascular disease and a 10% or greater risk of having a heart attack or stroke in the next 10 years. Those risk factors include diabetes, high blood pressure, smoking or high cholesterol. To calculate a person’s risk score, doctors also take into account factors like a person’s age, sex, race, blood pressure, cholesterol numbers and family history.

For people who have a slightly lower 7.5% to 10% risk of having a heart attack or stroke in the next 10 years, the latest guidance recommends that they talk to their doctor and then decide if they should take statins.

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Because the risk is slightly lower with this group, the benefits are smaller, even though they are still effective. In this case, the patient should talk to their doctor to determine if, based on individual factors, they need to take one. “There are other factors at the individual level that a healthcare professional and a patient can together decide what might be best for that patient because there are other ways of lowering your risk for having a stroke or first heart attack,” according to task force member Dr. John Wong, a professor of medicine at Tufts University. That includes things like diet and exercise.

For adults 76 and older, there was not enough research to make a recommendation about taking a statin for the first time.

The last time USPSTF revised its statin guidelines was in 2016. Since then, there have been several new studies that determine how effective statins are, Wong said.

The bottom line, Wong said, is that 40 years of science have shown that statins are safe and a good primary prevention that can reduce a person’s risk of developing or dying from heart problems.

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To make these recommendations, USPSTF reviewed 26 studies to compare the results from people who took statins and those who didn’t. The studies involved more than half a million patients.

“Statins were significantly associated with decreased risk of all-cause mortality,” the study said. This was true for all demographics.

The risk of taking statins, based on these studies, seemed small. In the past there had been some concern that statins may elevate a person’s risk for muscle problems or diabetes, but other than one study that involved high-intensity statin therapy, on the balance, these latest studies used to create these guidelines did not show real increase in either problem, experts said.

What other guidelines recommend

An editorial that accompanied the recommendations in JAMA suggested that these guidelines should have been more aggressive and better matched to cholesterol guidelines recommended by the American College of Cardiology and the American Heart Association. Those guidelines recommend statins for adults ages 40 to 75 who have a 7.5% or greater risk of having a heart attack or stroke in the next 10 years, as opposed to a 10% risk. The ACC/AHA guidelines also recommend statins for patients with diabetes without having to also calculate a person’s 10-year risk score and recommend statins for those patients with extremely high levels of cholesterol.
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“Individuals with higher baseline risks have greater absolute benefits from intervention than the lower-risk population. Were statins either risky or expensive, such a tailored treatment strategy would be reasonable. However, statins are now available as generic drugs and are both safe and affordable,” wrote the doctors at University of Texas Southwestern Medical Center in Dallas in an editorial.

Dr. Edward Fry, the president of the ACC, said it is important to keep in mind that the USPSTF guidelines are statements that are to be applied to a broad group or population of patients, whereas the ACC/AHA guidelines are directed more toward the individual. Neither make statins an automatic decision for a patient.

“Any medical decision needs to be made in an individual context and these guidelines give a sort of roadmap. There may be several different routes to get to where you want to go, but this is a roadmap,” Fry said. “The distinctions between the guidelines are relatively small.”

One area not touched on in the USPSTF guidelines, for instance, is a person’s coronary calcium score. A heart scan can look for calcium in the coronary arteries. There’s a relationship between calcium and plaque. For a patient that is borderline between a high or intermediate risk, that score could be used as another determining factor.

Other factors ACC/AHA’s guidelines take into account that are not a part of the USPSTF calculus, are what doctors call “risk enhancers” that could also help with decisions about those borderline cases. For example, a 35-year-old who has a family history of heart disease and high cholesterol would not be included in these guidelines, but may be a good candidate for a statin, according to Dr. Salim Virani, a professor of medicine in the section of cardiovascular research at Baylor College of Medicine.

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“The risk enhancers may increase a patient’s short-term, 10-year risk, or in some cases, their lifetime risk of having a cardiovascular event, then those guidelines recommend that clinicians should err on the side of early treatment, something not considered in the US Preventive Services Task Force recommendations,” Virani said. “But I do want to emphasize, even if clinicians were to take the more conservative US Preventive Service Task Force recommendations and follow them very, very aggressively, we definitely will see a population-level impact because of the statin therapy. It’s really been studied for a very, very long time and now we know it works.”

Dr. Ian Neeland, a cardiologist at the University Hospitals Harrington Heart & Vascular Institute and the Director of UH Center for Cardiovascular Prevention, who did not work on either guidelines, said the other big takeaway from the USPSTF is a “reaffirmation” of their earlier guidelines and that the science they used clearly show that statins are safe.

“Overall, the serious risk for serious, adverse events is very low and so the risk benefit will usually be in favor of a statin for individuals at risk,” Neeland said.

“Statins can be very helpful for long-term risk reduction and with very minimal side effects and great benefits. It’s one of those key medications that have changed the face of medicine,” Neeland added.

Also he said it’s important to keep in mind that guidelines are just guidelines. “They need to be used in clinical context and within the art and science of medicine,” Neeland said.

Virani said more has to be done to prevent heart problems.

“We are definitely facing a big wave of cardiovascular disease in our nation and we really need to treat it by both lifestyle therapies as well as medications when indicated,” Virani said.

What patients can do

Virani said it’s important for patients to ask their providers what their 10-year risk of having a heart attack or stroke is. It’s a calculation that needs the knowledge of an expert and cannot be done on one’s own.

“Having this conversation does not mean you need to be put on a therapy, but it will lead to a lot of important discussions even related to your lifestyle,” Virani said.

And statins, of course, aren’t the only way to help a person prevent a heart attack or stroke.

Both USPSTF and ACC/AHA recommend patients should stop smoking, be physically active and eat a healthy diet to lower their risk.

“Statins are one piece of the prevention wheel. They are not the only piece,” Neeland said. “There’s diet, physical activity, maintaining a healthy weight, blood pressure control, making sure you control diabetes or a risk for diabetes. All those aspects play into heart health. Statin medication is one way to reduce risk.”

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