Latest statin guidelines maintain more conservative approach to preventing first stroke or heart attack

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

Specifically, USPSTF guidelines published Tuesday at JAMA recommends statins for adults ages 40 to 75 who have one or more risk factors for cardiovascular disease and a 10% or greater risk of having a heart attack or stroke in the next 10 years. These risk factors include diabetes, high blood pressure, smoking, or high cholesterol. To calculate a person’s risk score, doctors also consider factors such as age, gender, race, blood pressure, cholesterol level, 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 guidelines recommend talking to their doctor and then deciding if they must take statins.

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Because the risk is slightly lower with this group, the benefits are less, although still effective. In this case, the patient should speak to their doctor to determine if, based on individual factors, they should take one. “There are other factors at the individual level that a healthcare professional and patient can decide together what might be best for that patient, because there are other ways to reduce your risk of having an accident. stroke or a first heart attack,” according to a member of the task force. Dr. John Wong, professor of medicine at Tufts University. This 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 the USPSTF revised its statin guidelines was in 2016. Since then, several new studies have determined the effectiveness of statins, Wong said.

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

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To make these recommendations, the USPSTF reviewed 26 studies to compare the outcomes of people who took statins and those who did not. The studies involved more than half a million patients.

“Statins were significantly associated with a 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 low. In the past, there were concerns that statins might increase the risk of muscle problems or diabetes, but aside from one study that involved high-intensity statin therapy, overall, these latest studies used to create these guidelines did not show a real increase in either problem, experts said.

What other guidelines recommend

An editorial that accompanied the JAMA recommendations suggested that these guidelines should have been more aggressive and better suited to cholesterol guidelines recommended by the American College of Cardiology and the American Heart Association. These guidelines recommend statins for adults aged 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 risk of 10%. 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 patients with extremely high cholesterol levels.
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“People with higher baseline risks benefit in absolute terms from the intervention than the low-risk population. If statins were 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 the University of Texas Southwestern Medical Center at 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 should be applied to a broad group or population of patients, whereas the ACC/AHA guidelines are more individual oriented. Neither makes statins an automatic decision for a patient.

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

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

Other factors considered by ACC/AHA guidelines that are not part of the USPSTF calculation are what doctors call “risk factors” that could also help make decisions about these cases. limits. For example, a 35-year-old person who has a family history of heart disease and high cholesterol would not be included in these guidelines, but could be a good candidate for a statin, according to Dr. Salim Virani, professor of medicine at the Cardiovascular Research Section at Baylor College of Medicine.

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“Risk factors can increase a patient’s short-term 10-year or, in some cases, lifetime risk of having a cardiovascular event, so these guidelines recommend that clinicians err on the side of one early treatment, which is not considered in the recommendations of the US Task Force on Preventive Services,” Virani said. “But I want to emphasize that even if clinicians were to follow the more conservative recommendations of the task force of American work on preventive services and following them very, very aggressively, we will definitely see an impact at the population level because of statin therapy. It’s really been studied for a long, long time and now we know it works.”

Dr. Ian Neeland, a cardiologist at University Hospitals Harrington Heart & Vascular Institute and director of the UH Center for Cardiovascular Prevention, who hasn’t worked on any of the guidelines, said the other big takeaway from the USPSTF is a “restatement” of their previous guidelines and that the science they used clearly shows that statins are safe.

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

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

He also said it’s important to keep in mind that guidelines are just guidelines. “They should be used in a clinical setting and in the art and science of medicine,” Neeland said.

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

“We are definitely facing a big wave of cardiovascular disease in our country and we really need to address it with both lifestyle therapies as well as medications when appropriate,” Virani said.

What Patients Can Do

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

“Having this conversation doesn’t mean you have to go to therapy, but it will lead to a lot of important conversations, even related to your lifestyle,” Virani said.

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

The USPSTF and ACC/AHA recommend that patients quit smoking, be physically active, and eat a healthy diet to reduce their risk.

“Statins are one piece of the prevention wheel. They’re not the only piece,” Neeland said. “There’s diet, physical activity, maintaining a healthy weight, controlling blood pressure, controlling diabetes or the risk of diabetes. All of these aspects play into heart health. Statins are a way to reduce risk.

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