The background prevalence of disease in the population is key in this argument. If an increasingly larger proportion of the entire population needs to be targeted, putting more people (they are not patients) on statins may paradoxically may be the wrong approach.
Firstly, the pre-test probability of high future cardiovascular risk will reduce the wider one casts the net as the prevalence of high-risk individuals reduces, and hence the number of false positives (individual falsely identified as having a high cardiovascular risk) will increase. Paradoxically, if one suspects that most of the population has a high pre-test probability of being at risk of future premature cardiovascular disease, then does it then follow that we should we treat and medicalise all adults? With the high absolute numbers of false positives with such an approach, the side-effects of statins may over-ride their benefits. If however most of the population is at risk of future premature cardiovascular disease, then putting statins for example in the tap water would still be unacceptable.
Arguably, this is an incorrect solution anyway, as drugs do not eliminate the underlying societal-level causes of the disease. For example, the nutrition transition in developed, and increasingly, in developing countries(2) should be dealt with by a change in food policy, not using cholesterol-lowering medication to deal with its consequences. Encouraging the whole-population uptake of healthy behaviours through changes in food and physical activity policies, especially where individual choice is not working, is preferable to the widespread taking of tablets as a population-level intervention. These strategies may be preferable rather than casting the statin net out further.
1. Wilson J, Jungner, G. Principles and Practice of Screening for Disease. WHO Chronicle 1968;22(11):473.
2. Drewnowski A, Popkin BM. The nutrition transition: new trends in the global diet. Nutr Rev. 1997 Feb;55(2):31-43.
Competing interests:
No competing interests
31 July 2014
M Justin Zaman
Consultant Cardiologist and Honorary Senior Lecturer in Cardiovascular Epidemiology
James Paget University Hospital and the University of East Anglia, Norfolk, UK
Lowestoft Rd, Gorleston-on-Sea, Great Yarmouth, Norfolk NR31 6LA
Rapid Response:
The background prevalence of disease in the population is key in this argument. If an increasingly larger proportion of the entire population needs to be targeted, putting more people (they are not patients) on statins may paradoxically may be the wrong approach.
Firstly, the pre-test probability of high future cardiovascular risk will reduce the wider one casts the net as the prevalence of high-risk individuals reduces, and hence the number of false positives (individual falsely identified as having a high cardiovascular risk) will increase. Paradoxically, if one suspects that most of the population has a high pre-test probability of being at risk of future premature cardiovascular disease, then does it then follow that we should we treat and medicalise all adults? With the high absolute numbers of false positives with such an approach, the side-effects of statins may over-ride their benefits. If however most of the population is at risk of future premature cardiovascular disease, then putting statins for example in the tap water would still be unacceptable.
Arguably, this is an incorrect solution anyway, as drugs do not eliminate the underlying societal-level causes of the disease. For example, the nutrition transition in developed, and increasingly, in developing countries(2) should be dealt with by a change in food policy, not using cholesterol-lowering medication to deal with its consequences. Encouraging the whole-population uptake of healthy behaviours through changes in food and physical activity policies, especially where individual choice is not working, is preferable to the widespread taking of tablets as a population-level intervention. These strategies may be preferable rather than casting the statin net out further.
1. Wilson J, Jungner, G. Principles and Practice of Screening for Disease. WHO Chronicle 1968;22(11):473.
2. Drewnowski A, Popkin BM. The nutrition transition: new trends in the global diet. Nutr Rev. 1997 Feb;55(2):31-43.
Competing interests: No competing interests