Educating patients in primary care remains challenging
The latest guidelines on statin treatment for the primary prevention of cardiovascular disease aimed to address criticisms that previous recommendations made too many low-risk individuals candidates for statin therapy.
The 2018 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines call on clinicians to discuss therapy based on the patient's individual risk factors, including 10-year atherosclerotic cardiovascular disease risk calculation, comorbidities, and personal history. The discussion should also include potential side effects of statin therapy, cost, and patient preferences regarding treatment.
A previous recommendation was also upgraded regarding the use of coronary artery calcium (CAC) testing in intermediate-risk adults with low density lipoprotein (LDL) cholesterol in the range of 70 to 189 mg/dL and a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5% to 19.9% (upgraded from a 2b to 2a recommendation).
Like the earlier guidelines, some components of the 2018 revision are controversial, and confusion remains about how clinicians can best advise patients with an intermediate or uncertain risk for cardiovascular events.
Howard Weintraub of NYU Medical Center and NYU School of Medicine, said it is not realistic to expect a family practitioner or internist to be able to take the time to have nuanced discussions about the benefits and risks of taking a statin.
"Having a discussion that encompasses the pros and cons of statin use in individuals who are at intermediate [CVD] risk is not something that happens in the course of a few minutes," he told MedPage Today. "I would imagine it isn't happening much at all."
He said generalists are also not ordering CAC testing, which is largely not paid for by insurance. Instead, many are still "treating the number" -- i.e., recommending statin treatments to intermediate-risk patients largely based on their LDL level.
Or, perhaps, just avoiding the issue entirely, findings from a recently published study suggest.
More than half of people surveyed who were eligible for therapy but not taking a statin said they were never offered the treatment by a clinician.
The study included 5,693 adults eligible for statin therapy based on the Patient and Provider Assessment of Lipid Management Registry.
Just over 1,500 participants (26%) were not on a statin, and 59.2% reported that they were never offered the treatment. Another 10% were offered treatment but declined, and around 30% had discontinued the therapy.
Women (relative risk 1.22), black adults (RR 1.48), and the uninsured (RR 1.38) were more likely to report not being offered a statin.
Compared with statin users, those who declined or discontinued statins were less likely to believe statins are safe (70.4% of current users vs 36.9% of decliners and 37.4% of those who discontinued statin use).
ACC, AHA, and other health groups have extended their online efforts to help intermediate-risk patients navigate decisions about statin use.
But Weintraub said the groups are fighting an uphill battle.
"The average 35- or even 40-year-old is far more likely to just Google than go to the AHA website," he said. "That's where they are becoming educated, and the prevailing message is 'statins are poison' and 'statins are part of a conspiracy by Big Pharma.'"
However, the upgraded recommendation favoring the use of CAC as a tie-breaker on statin use for intermediate-risk patients is also not without its critics.
In a study published last December in the Journal of the American College of Cardiology, CAC scoring identified patients without baseline ASCVD who would not benefit from statin therapy with a high degree of accuracy in asymptomatic people.
Treatment with a statin was associated with a reduced risk of major adverse cardiovascular events (MACE) in patients with CAC (adjusted subhazard ratio 0.76; 95% CI 0.60-0.95; P=0.015), but not in patients without CAC (adjusted subhazard ratio of 1.00, 95% CI 0.790-1.27; P=0.99).
The effect of statin treatment on MACE was found to be significantly related to CAC severity, with the number needed to treat to prevent one MACE over 10 years ranging from 100 (CAC 1-100) to 12 (CAC over 100).
But the U.S. Preventive Services Task Force does not endorse CAC for cardiovascular assessment in people without CVD symptoms, noting that "the current evidence is insufficient to assess the balance of benefits and harms" for CAC testing in this group.
And the test has been shown to have limited prognostic value in at least one group of patients who might fall into the intermediate CVD category -- smokers.
In a study that followed active smokers and nonsmokers for 15 years, the presence of CAC was found to be highly predictive of all-cause mortality in older smokers.
But active smokers with a CAC score of zero also had elevated risk.
This finding led the researchers to conclude that "for smokers, a CAC=0 should not be considered a negative risk factor."
"A CAC of zero can represent a 'get-out-of-jail-free' card for everyone except smokers, diabetics, and people with familial hypercholesterolemia," Weintraub said, adding that people with diabetes and those with familial hypercholesterolemia are considered to have an elevated CVD risk.
Read the original article on Medpage Today: Clinical Challenge: Applying New Lipid Guidelines