A resident asked me the other day whether to put someone on a statin. The patient had an LDL of 136, but was not high risk. My instinctive answer was to recommend against taking a statin, but the resident argued that the patient had a Framingham risk of 10%. We did not resolve our debate at that time.
Our debate is not unique. Therefore, these Canadian investigators examined the question carefully – Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study
Abstract
Objective To examine the potential effectiveness and efficiency of different guidelines for statin treatment to reduce deaths from coronary heart disease in the Canadian population.
Design Modelled outcomes of screening and treatment recommendations of six national or international guidelines—from Canada, Australia, New Zealand, the United States, joint British societies, and European societies.
Setting Canada.
Data sources Details for 6760 men and women aged 20-74 years from the Canadian Heart Health Survey (weighted sample of 12 300 000 people) that included physical measurements including a lipid profile.
Main outcome measures The number of people recommended for treatment with statins, the potential number of deaths from coronary heart disease avoided, and the number needed to treat to avoid one coronary heart disease death with five years of statin treatment if the recommendations from each guideline were fully implemented.
Results When applied to the Canadian population, the Australian and British guidelines were the most effective, potentially avoiding the most deaths over five years (> 15 000 deaths). The New Zealand guideline was the most efficient, potentially avoiding almost as many deaths (14 700) while recommending treatment to the fewest number of people (12.9% of people v 17.3% with the Australian and British guidelines). If their “optional” recommendations are included, the US guidelines recommended treating about twice as many people as the New Zealand guidelines (24.5% of the population, an additional 1.4 million people) with almost no increase in the number of deaths avoided.
Conclusions By focusing recommendations on people with the highest risk of coronary heart disease, the Canadian, US, and European societies guidelines could improve either their effectiveness (in terms of hundreds of avoided deaths) or efficiency (in terms of thousands of fewer people recommended treatment) in the Canadian population.
The article does a nice job discussing why the guidelines differ. I believe their result – we should be very aggressive in statin use for patients having coronary artery disease, or those of highest risk (type II diabetes mellitus, very strong family history, chronic kidney disease stage III). We need not be as aggressive in patients without high risk.
I think my instinct was correct. I would not treat the patient in question.
