1. Primary Prevention of Cardiovascular Disease (CVD) Events with Statins
Alternate title: “Who should receive statins for primary prevention?”

2. Objectives
Review recommendations for use of statins for primary prevention
Use CVD risk and patient preferences to guide decision making about statins
Answer questions about practical issues in risk- based primary prevention
Note: Dr. Pignone is a former member of the US Preventive Services Task Force- the views expressed here are his and not necessarily those of the USPSTF. He has no additional disclosures to report.

3. Why is lipid screening and treatment important?
Abnormal lipid levels increase the risk of cardiovascular events 
Cardiovascular disease is the leading cause of morbidity and mortality in adults
Treating abnormal lipid levels can prevent CVD events and premature deaths

4. Statins are effective for primary prevention
Statins reduce CVD events by 25-30%
14% reduction in all-cause mortality
Diet and exercise counseling have independent effects on CVD risk
Cochrane Database Syst Rev. 2013 Jan 31;1:CD doi: / CD pub5.
Statins for the primary prevention of cardiovascular disease.
Taylor F1, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S.
Taylor et al Cochrane Review 2013

5. Statins reduce CHD events by 36%

6. Statins reduce all-cause mortality by 14%

7. 2013 ACC/AHA recommendations
Stone et al J Am Coll Cardiol. 2014;63(25 Pt B):

8. 2016 USPSTF guidelines

9. Our synthesis 10-year CVD risk < 5%
No treatment (unless extreme LDL elevation: > 190 mg/dl)
5-10%
Consider statin; Use shared decision making
>10%
Encourage statin use

10. Statins for primary prevention
CVD risk reduction with statins proportional to LDL reduction
No trials compare different “goal” lipid levels
Use a moderate dose, generic statin
High-dose statins may provide incremental benefit for higher risk primary prevention but also have additional harms
Frequent monitoring of lipid levels during treatment is not beneficial

11. ACC-AHA global risk calculator

12. CVD risk output (and treatment recommendation)

13. Questions
How should family history be incorporated into decision making about risk calculation?
Should risk be re-calculated after initial treatment?
Why use a higher risk threshold (10%) for recommending treatment?

14. How to incorporate family history into risk calculation?
Family history of early myocardial infarction is a risk factor for future events
Much of the effect of family history is mediated through traditional risk factors
If a patient has a strong family history, it may be a reason to treat at more moderate risk levels (5-10%)

15. Re-calculation of risk
Risk calculator is designed to be used before treatment with statins has been initiated
Once treatment has been started, the estimation of future risk may be somewhat compromised, but is not too inaccurate
If post-treatment risk remains high, ask whether the post-treatment lipid levels reflect the degree of reduction anticipated
If not, check adherence and make sure dosage is appropriate; if reduction is appropriate, consider other risk factor reduction

16. Why use a 10% threshold for recommending treatment?
Greater confidence that benefits >> downsides
Corrects for possible over-estimation of risk with ASCVD risk calculator
Emphasizes the importance of shared decision making – can help build adherence!

17. Conclusions
Use risk factor information and risk calculator to guide treatment recommendations
Prescribe moderate dose, generic statin for patients with 10 year CVD risk >10%
Consider shared decision making for those at % risk

18. Other questions?