In 2016 the U.S. Preventive Services Task Force (USPSTF) released new statin
guidelines for the primary prevention of cardiovascular disease (CVD) in adults. Primary prevention refers to measures taken to prevent CVD among individuals without overt evidence of CVD. The recommendations are:

• Initiate use of low- to moderate-dose statins in adults aged 40 to 75 years
without a history of CVD who have one or more CVD risk factors abnormal
blood lipids, diabetes, hypertension, or smoking and a calculated 10-year CVD
event risk of 10% or greater.
• Selectively offer low- to moderate-dose statins to adults aged 40 to 75 years
without a history of CVD who have one or more CVD risk factors and a
calculated 10-year CVD event risk of 7.5% to 10%.
• Current evidence is insufficient to assess the balance of benefits and harms of
initiating statin use in adults 76 years and older.

In a 2016 editorial in the JAMA, Greenland pointed out that including the USPSTF
statement, five different guidelines for statin use have been published since 2013.
He notes that there is a lack of agreement on specific LDL-C targets of therapy and
on specific treatment initiation thresholds, with the 2013 ACC/AHA guideline recommending
the lowest threshold. All five of the guidelines uniformly advise that
clinical judgment, along with thoughtful patient-clinician discussion, is indicated,
regardless of the level of patient risk. All guidelines also emphasize the importance
of lifestyle interventions to reduce risk in all patients, regardless of lipid-lowering
drug use.

Greenland has what he calls several important take-home messages:

• Ensure statin use by higher-risk patients. Every patient at age 40 years or older
should be considered for possible statin therapy.
• Additional testing can inform the patient-physician discussion.
• Based on data from younger patients, it is reasonable to treat otherwise
healthy individuals older than 75 years.
• Last, and perhaps most important, clinical judgment and patient input are
critical components of the decision process, especially for older patients and
those at a lower risk.

In an additional editorial comment on the USPSTF guidelines, Gurwitz and colleagues
note that although compelling evidence exists supporting statins for secondary
prevention in individuals younger than 75 years with clinical arteriosclerotic
CVD, there is less evidence of their utility for primary prevention in older
age groups. In one study, a subgroup analysis of men and women aged 70 to 82
years, found that statin therapy had no statistically significant effect on the primary
composite outcome (coronary death, nonfatal myocardial infarction, and fatal or
nonfatal stroke). In contrast, a meta-analysis of 28 clinical trials that included
14,000 people over age 75 found that statins reduced major CVD events similarly
for all age groups—by about 20%. But with increasing age, there was a trend
towards smaller relative risk reductions in vascular event and mortality outcomes.

A 2020 study published in the JAMA found that initiating statin use among nearly
327,000 veterans at an average age of 81 was associated with 25% fewer deaths
from all causes and 20% fewer CVD deaths. All study subjects were free from
CVDs at the start of the nearly 7-year study, 97% were men and 91% were white, so
the relevance of the study to women, more diverse populations and those with preexisting CVDs is less certain than it is for white men. An editorial that accompanied the study concluded that although additional studies are needed, “These findings
provide a compelling argument for the use of statins for primary prevention in older
patients.”

In an editorial comment in JAMA on the new USPSTF guidelines, Redberg and
Katz expressed reservations about use of statin therapy for primary prevention of
CVD by older adults. They pointed out that even though some studies have estimated
that close to 20% of statin users have muscle problems, many of the trials did
not ask about commonly reported statin effects, such as muscle pains and weakness,
and only recorded myopathy—a rare side effect. Redberg and Katz note that
persons at low risk who have little chance of benefit have an equal chance of harms,
and unfortunately, the evidence base for harms of statins is incomplete. Harms may
include more obesity and more sedentary behavior because people on statins may
mistakenly think they do not need to eat a healthy diet and exercise as they can just
take a pill to give them the same benefit. Their summary comment is, “Given the
serious concerns about the harms of the reliance on statins for primary prevention,
it is in the interest of public health and the medical community to refocus efforts on
promoting a heart-healthy diet, regular physical activity, and not smoking.”

This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel