Statins for primary prevention of cardiovascular disease

Statistics from the Organisation for Economic Co-operation and Development show that the per capita use of statins in the United Kingdom is the highest in Europe and the second highest of all OECD countries.1 Several factors account for the high use of statins in the UK, including the emphasis on evidence based medicine in the training of UK doctors; the 2004 contract for general practitioners, which introduced financial incentives for the management of long term conditions such as coronary heart disease and diabetes; and the NHS Health Check programme, which aims (among its objectives) to increase the use of statins for the primary prevention of cardiovascular disease in England in people who have a 20% or more 10 year risk of such disease.

The UK National Institute for Health and Care Excellence is now proposing to reduce the threshold for starting statins for the primary prevention of cardiovascular disease from its current threshold of a 20% 10 year risk to a 10% 10 year risk.2 Although this could have major benefits for population health by substantially increasing the number of people who would be eligible for statins for the primary prevention of cardiovascular disease, three key issues need to be considered if we are to implement this policy successfully.

Firstly, general practices (the main route for assessing cardiovascular risk and prescribing long term statins) are currently under considerable workload and financial pressure. The BMA and the Royal College of General Practitioners have launched public campaigns to make people aware of this pressure and to try to increase the resources going to primary care.3 (In recent years, the BMA has reported, the proportion of the NHS budget spend going to primary care has fallen from around 11% to 8%.) In its draft guidance, NICE did not attempt to assess the workload implications of its proposed 10% 10 year risk threshold or how this additional work would be funded. Furthermore, despite already being overstretched and underfunded, general practices will have other major new areas of work to take on, such as hospital admission avoidance schemes, improved care for older patients, longer opening hours, and more rapid access for people with acute medical problems. General practices may not be able to cope with all these additional areas of work and at the same time further expand access to statins unless the government were to increase the funding that general practices receive.

Secondly, patients need to be convinced to take statins, particularly those with lower levels of cardiovascular risk who may perceive themselves as being healthy and who may not be keen on long term drug treatment. Early results from local evaluations of the NHS Health Check programme are not encouraging.4 Only a minority of patients attended for their NHS Health Check after they received an invitation, and a substantial proportion of patients who did attend and who were found to have a high 10 year cardiovascular risk did not subsequently start treatment with statins.5 Clearly, much work needs to be done by general practices, local authorities (now responsible for commissioning the NHS Health Check programme), and Public Health England to convince people who think they are healthy to start long term statin treatment. Convincing people to take statins may be even more difficult in those with a 10 year risk of cardiovascular disease of between 10% and 20% if the proposed NICE guidelines are adopted into clinical practice and 10% becomes the threshold risk level for starting treatment.

Finally, what is the true level of side effects from statins?6 Millions of people in the UK are taking statins without suffering any major problems. But there are differences in the risk of side effects shown in clinical trials and in data derived from electronic medical records, which generally report a higher incidence of adverse events in people taking statins than has been reported in clinical trials. This discordance between the evidence from clinical trials and from clinical practice needs to be investigated so that doctors and patients are given accurate information about the risks and benefits of long term statin treatment.