How should we balance individual and population benefits of statins for preventing cardiovascular disease?

Guideline groups in the United Kingdom and the United States are reviewing recommendations for the primary prevention of cardiovascular disease. At their disposal will be good quality evidence on the quantitative relation between the major risk factors and the probability of a first cardiovascular event1; the extent of the current population exposure to risk factors2 3; and the safety and efficacy of drugs to lower blood pressure and cholesterol concentrations.4 5 The decisions of these expert groups will have far reaching consequences for the millions of adults in both countries, where cardiovascular disease is the biggest cause of mortality and morbidity; around half of men and a third of women have a cardiovascular event during their life.6

There are new drivers to modify the existing guidance (table 1⇓; box), and two extreme positions could be envisaged (table 2⇓). The first is to redouble efforts to identify high risk individuals by enhancing currently used risk prediction tools with new information from blood biomarkers or non-invasive vascular imaging; to treat those at high risk with newer more expensive statins that achieve the greatest cholesterol reduction; and to tailor treatment for each individual to achieve target cholesterol levels. The interest in C reactive protein as a new biomarker of cardiovascular risk7 and the recent US Food and Drug Administration licence extension of the patent for rosuvastatin, with C reactive protein as a companion test, suggests that the US could follow this course. The diametric alternative is to use generic versions of the older …