Cholesterol-Fighting Statins: New U.S. Guidelines for Those Over 40

More people over the age of 40 should be screened for cholesterol-busting statin drugs regardless of whether they have a history of cardiovascular disease, according to a U.S. panel of independent experts commissioned by the government.

The new guidelines from the U.S. Preventive Services Task Force (USPSTF), published in JAMA, suggest that the following category of Americans be put on statins: People ages 40 to 75 who have one or more risk factors – such as high cholesterol, high blood pressure, diabetes or smoking — and who are at a 10 percent or greater risk of having a heart attack or stroke in the next 10 years.

The USPSTF makes regular recommendations to the medical community. But the broad and growing use of statins has generated much debate.

There is a consensus among doctors that people at substantial risk for heart disease benefit from statins, but there is considerable disagreement about those at lower risk, many of whom can benefit primarily from lifestyle modifications to achieve or maintain a healthy weight and lower risk factors without medications that can produce side effects.

Statins, which have been found to reduce cardiovascular disease and mortality in those who are at high risk, are among the best-selling drugs in the United States. Doctors assess a patient’s 10-year risk of having a heart attack or stroke based on a calculation using age, cholesterol and blood pressure readings, family medical history, lifestyle habits such as smoking and other metrics.

“Results from our analysis support the focus on prevention, as well as expansion of screening and counseling for modifiable cardiovascular risks, which are lifestyle factors that individuals can control through healthier choices,” said Khurram Nasir, M.D., Medical Director of the Center for Healthcare Advancement & Outcomes at Baptist Health South Florida. “These efforts can play a critical role in containing healthcare costs and improving patient health.”

While statin use has increased substantially over the last 12 years, usage has not risen at the same rate among high-risk groups, according to a separate study published Monday in JAMA Cardiology. The 12-year study of U.S. adults 40 years and older also evaluated the use of brand versus generic use of statin drugs and the relationship drug cost had on patient usage.

The study found that among U.S. adults 40 years of age and older, statin drug usage increased almost 80 percent from 21.8 million individuals (17.9 percent) in 2002-2003 (134 million prescriptions) to 39.2 million individuals (27.8 percent) in 2012-2013 (221 million prescriptions).

What About People With Lower Risks?

In its new report this week, the USPSTF says that people with a slightly lower risk, 7.5 percent to 10 percent, may also benefit. The USPSTF “recommends that clinicians selectively offer low- to moderate-dose statins” to those with a risk of less than 10 percent of having a heart attack or stroke in the next 10 years.  But the experts conceded that in these individuals there is greater uncertainty related to the use of statins.

“Although statin use may be beneficial for the primary prevention of CVD (cardiovascular disease) events in some adults with a 10-year CVD event risk of less than 10 percent, the likelihood of benefit is smaller, because of a lower probability of disease and uncertainty in individual risk prediction,” the USPSTF says.

Bigger Focus on Lifestyle Factors
The newest recommendations support the position of the American College of Cardiology and the American Heart Association, which in 2013 modified their advice from suggesting that doctors focus on the level of a patient’s low-density lipoproteins (LDL) or “bad cholesterol” to looking at a more comprehensive picture of risk based on things such as weight and blood pressure, along with lifestyle factors that include nutrition and exercise.

“People with no signs, symptoms, or history of cardiovascular disease can still be at risk for having a heart attack or stroke,” explained Kirsten Bibbins-Domingo, who chaired the task force.

The task force withheld a recommendation about starting statins in adults who are 76 and older, saying that “the current evidence is insufficient to assess the balance of benefits and harms.”

The USPSTF says that clinicians may choose to offer a low- to moderate-dose statin to certain adults without a history of cardiovascular disease when all of the following criteria are met:

1) They are aged 40 to 75 years;

2) They have 1 or more cardiovascular disease risk factors (for example: high cholesterol, diabetes, hypertension, or smoking);

3) They have a calculated 10-year risk of a cardiovascular event of 7.5 percent to 10 percent.