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CARDIOLOGY

Controversy, primary prevention of cardiovascular disease, low-risk patients should not use statins?

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Recently, the latest analysis published online by BMJ indicates that the cost-effectiveness of statins in low-risk patients is lower, with less benefit and potential adverse effects.Researchers believe that under certain circumstances, this may be a waste of medical resources.Researchers led by Professor Paula Byrne of the National University of Ireland, Galway, point out that in primary prevention, it is uncertain whether the benefits of statins are greater than their potential harm, and whether it is possible to prove the widespread use of statins from a social perspective.The rationality of the drug.However, over time, clinical guidelines have expanded the indications for statins in primary prevention.In many countries, most statin users are also committed to primary prevention.Therefore, Professor Byrne and others want to know who is taking statins, why they take statins, and how they benefit from taking statins, especially for those who have not yet developed cardiovascular disease (in this population)The statin application is still controversial).To get an answer, Byrne et al. used data from the Irish National Elderly Cohort to analyze the impact of changes in the European Cardiovascular Disease Prevention Guidelines from 1987-2016 on statin use.According to Byrne, 30% of the population over the age of 50 use statins, and two-thirds of them use primary prevention.Among the female population taking statins, 3/4 had primary prevention; in male patients, it was only more than half.Because there are more patients with primary prevention of statins, it is necessary to clarify the benefits of statins in such patients.After applying the guidelines from different periods of the past 30 years to the Irish cohort study, the researchers found that only 8% of the subjects met the statin use criteria according to the 1987 guidelines; 61% of the subjects according to the 2016 guidelinesIt can be treated with statins.Byrne thinks this is a huge increase.The researchers then began looking for evidence to support the use of statins in primary prevention.Although many studies and meta-analyses related to statins have been discovered, primary prevention and secondary prevention have been distinguished in fewer studies.After screening, only three systematic reviews reviewed statin primary prevention.Among them, two reviews from the Cholesterol Treatment Trial Collaborative Group (CCT) analyzed the same data and were considered a data set; the authors of the other two reviews were Mora et al. and Ray et al.According to the 1994 guidelines, the number of patients (NNT) required to prevent a cardiovascular event in primary prevention is 40.Byrne thinks this is a fairly reasonable number.However, according to the 2016 guide, the NNT is 400.In this regard, Byrne said that the benefits of statin treatment were greatly reduced according to the 2016 guidelines.The choice of low benefit benefits is two examples of primary prevention. Patients have different risks and the absolute benefits of taking statins are quite different.The first case: 60 years old, male, smoking, no heart disease, elevated total cholesterol levels, elevated blood pressure, predicts an absolute risk of coronary events of 38% within 10 years.After statin therapy, the absolute risk can be reduced by about 9% (NNT = 11).The second case: 45 years old, female, no smoking, elevated total cholesterol levels, slightly elevated blood pressure, is expected to have a 10-year risk of 1.4%.However, after taking statins for treatment, the absolute risk was only reduced by about 0.6% (NNT = 166).In fact, their analysis showed that none of the low- and medium-risk populations who underwent primary prevention achieved a risk-reduction level to demonstrate that it is reasonable to take statins daily for prevention.In this regard, Byrne said that when the benefits are so small, whether or not to take the drug may depend on the potential harm caused by the drug.The authors believe that although the benefits are small, some clinicians and patients may still wish to reduce the risk of cardiovascular disease through statins.But for others, potential adverse reactions can seriously affect their decision making.However, in some related studies, the data of adverse reactions were not analyzed independently, and the specific hazards were still undetermined.Professor Byrne pointed out that according to CCT estimates, every 10,000 patients receiving statin therapy for 5 years can have 5 cases of myopathy, 50-100 cases of new diabetes and 5-10 cases of hemorrhagic stroke.Other data show a higher incidence of myopathy: 530 cases of myopathy can occur per 10,000 patients receiving statin for 5 years.We should obtain data from the study and conduct an independent analysis to make a more accurate assessment.Professor Byrne believes that patients should decide whether to take statins based on their benefits and risks.However, to do this, evidence of better benefits and risks must be obtained in the primary prevention population.We need to conduct more trials in low-risk populations, and there should be sufficient effectiveness in this population to assess uncertain groups such as women and old age.A better understanding of these uncertainties will help alleviate the pressure on GPs when prescribing drugs.Making the uncertainty more transparent will also help doctors and patients make better decisions.Expert comment: Conclusion “Unexpected” Professor Metin Avkiran from the British Heart Foundation (BHF) pointed out in the comments that the analysis is based on a large number of independent research evidence, and the conclusion is similar to what I expected.More than 20 years ago, clinical trials have demonstrated that statins can effectively reduce the risk of cardiovascular disease, and that patients with a history of heart disease and stroke also have greater benefits.The current debate is about the benefits of statin treatment in low-risk patients and whether the benefits outweigh their side effects.It believes that low-risk populations should be treated with statins and should be based on their discussions with the general practitioner..
Professor Avkiran said that he understands that patients are worried about the side effects of statins, and hopes that patients and doctors can make informed decisions about taking/prescribing statins based on evidence-based evidence.BHF is doing its best to fund researchers to collect and analyze data from subjects in large clinical trials of statins.Ending this debate will help stop conflicting reports, in case they stop people taking drugs that can save the lives of patients. , please do not reprint without the authorization of the copyright owner.

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