Statins for the primary prevention of cardiovascular diseaseBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g280 (Published 27 January 2014) Cite this as: BMJ 2014;348:g280
- Shah Ebrahim, professor of public health and policy1,
- Fiona C Taylor, managing editor, Cochrane Heart Group1,
- Peter Brindle, general practitioner2
- 1Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Health, London WC1E 7HT, UK
- 2Avon Primary Care Research Collaborative, Bristol Clinical Commissioning Group, Bristol BS1 3NX, UK
- Correspondence to: F C Taylor
- Accepted 8 January 2014
A 55 year old former financial services manager attended a cardiovascular risk check, which showed he had a 15% risk of suffering a major cardiovascular event in the next 10 years.1 He asks his general practitioner whether he needs a statin given his risk. His risk factors are being overweight; moderate smoker; blood pressure 150/90 mm Hg; and serum total cholesterol concentration 5.5 mmol/L, high density lipoprotein cholesterol 1.2 mmol/L, low density lipoprotein cholesterol 3.5 mmol/L, triglycerides 1.7 mmol/L.
What are statins?
Statins inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, involved in cholesterol biosynthesis. Low density lipoprotein (LDL) cholesterol concentration is lowered by reducing its production in the liver and increasing removal from the circulation.2 Lowering blood levels of LDL cholesterol, a major risk factor for cardiovascular disease, reduces the chances of having cardiovascular disease. Statins also have anti-inflammatory effects, improve endothelial function, and reduce thrombus formation, but these effects may not be independent of cholesterol lowering or reduce cardiovascular disease risk.3 Expert committees promote their use on a global scale,4 5 6 7 and statin prescribing and expenditure have risen rapidly. In England, prescriptions for statins rose fivefold from 2001 to 2011 to £61m a year (£544 average annual cost per person).8
How well do they work?
Statins are indicated for secondary prevention of cardiovascular disease. The Cholesterol Treatment Trialists Collaboration reviewed data from 27 clinical trials of statins (170 000 participants) for both primary and secondary prevention and reported a 20% relative risk reduction per 1 mmol/L reduction in LDL cholesterol concentration for major vascular events. These beneficial effects were seen in both men and women, at ages from <60 to >70 years, in people with and without cardiovascular disease, in those at high and low cardiovascular disease risk, in diabetics, and in those with average levels of blood cholesterol.9
A Cochrane …