The AusHEART study suggests that up to 30% of patients at low absolute CV risk are being prescribed a statin.3 Low-risk patients receive the least absolute benefit from lipid-modifying and BP-lowering medicines, and harms are likely to outweigh the benefits of treatment in many of these patients.4 Therefore, it is generally recommended not to prescribe lipid-modifying medicines for these patients.1,3,5
Patients identified as high CV risk should be prescribed a lipid-modifying medicine. These patients receive the greatest absolute benefit from statins, and include those who have had a previous CV event (secondary prevention).6,7 Additionally, a modelling study, cited by the National Vascular Disease Prevention Alliance, indicated that treating those at highest absolute risk is potentially more than twice as effective in reducing death from coronary heart disease than treating people with elevated cholesterol levels alone.8,9 Based on meta-analysis data of 27 clinical trials, authors predicted that 5 years of statin therapy that reduces LDL-C by 2.5 mmol/L has the potential to prevent 100 major vascular events per 1000 people treated in patients with ≥ 20% to < 30% absolute CV risk, compared to 12 events per 1000 in patients with < 5% risk.6
When lipid-modifying medicines are indicated, patients are usually started on a low dose of a statin10 which is titrated (if necessary) until target lipid levels or maximum tolerated dose (MTD) are achieved.1 In patients who have had a previous CV event, statins are usually started at a higher intensity (dose + potency) with lower LDL-C targets.11-13 The maximum response to a dose can usually be observed within 4 weeks of initiation or dose increase.14 Statin monotherapy should be trialled adequately which involves optimising adherence to medicine and lifestyle changes as well as titrating to MTD. If patients are persistently not meeting targets with optimal monotherapy, consider adding a second agent.