ABSTRACT
The evidence from randomized clinical trials of statins has such wide application that it has moved the management of the more common forms of dyslipidaemia from what was formerly the province of a few luminaries or, in the eyes of some, dangerous eccentrics, to occupy an important position in everyday clinical practice. The need to ensure that the statins are deployed as effectively as possible, and the enormous cost involved in their use because so many people can benefit from them in populations in which cardiovascular disease (CVD) risk is prevalent, have led to a series of recommendations for their clinical use from national and international organizations. It should be emphasized from the outset that both the cost and the benefit of statins to a society are largely determined by its typical absolute CVD risk (and that, in turn, by its nutrition and energy expenditure). Clearly, as statins become cheaper their cost will diminish. However, to translate the scientific evidence that statins prevent CVD fully, in the populations of countries such as the UK and USA most men from the age of 50 years onwards and most women from the age of 60 years require treatment because of their high risk. Statins are unique, not just because of the strength of evidence that they prevent CVD (21% reduction for each 39 mg/dl (1 mmol/l) reduction in low density lipoprotein [LDL]1), but also because they can potentially be taken by almost anyone. To take antihypertensive treatment, one has to have a raised blood pressure. The risk at which people can benefit from aspirin is much higher than that at which they can benefit from statin or antihypertensive therapy, because of the significant risk of cerebral or gastrointestinal haemorrhage.2,3 The potentially wider benefit from statins raises a number of issues. Not to offer
population screening for CVD risk, which could lead to the prescription of statins, would mean that a health-care system was failing to protect its members from what is their most likely cause of premature mortality and serious morbidity.We know that people whose CVD risk is 10% over the next 10 years can benefit from statin treatment.4 This is probably no more than the average risk in a middle-aged man in the USA and many parts of Europe, yet a 1 in 10 risk is not really a low risk. It is useless to argue that it is a level of risk at which statin treatment is not cost-effective, because judged against other treatments statins are cost-effective at levels of CVD risk even lower than 10% over the next 10 years.5,6 Another concern about the widespread use of statins in society is that large sections who might otherwise have considered themselves well will have health anxieties and the constant need to take medicine. This concern, of course, would apply only to people who were not already attending clinics as a consequence of diabetes, hypertension or pre-existing vascular disease – it really applies only to those apparently healthy people discovered by screening to have sufficient CVD risk to justify statin use. Does this decrease their quality of life to such an extent that it counteracts the benefit? Unlikely, when one considers the pre-existing high prevalence of self-medication with substances unlikely to yield any benefit,7 and the health improvements from reinforcement of advice to stop smoking and adopt a sensible diet and reasonable level of exercise that can come from regular contact with clinical services during the monitoring of statin treatment.8
