Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort

Paula Byrne; John Cullinan; Paddy Gillespie; Rafael Perera; Susan M Smith

doi:10.3399/bjgp19X702701

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Statins for primary prevention of cardiovascular disease
Padraig Dixon

Published on: 02 May 2019

Published on: (2 May 2019)
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Statins for primary prevention of cardiovascular disease
Padraig Dixon, Research Fellow in Health Economics, Population Health Sciences, Bristol Medical School, University of Bristol
Byrne et al.¹ study the impact of changing clinical guidelines for statin therapy in relation to the primary prevention of cardiovascular disease (CVD). The authors calculated numbers needed to treat (NNT) to prevent a major vascular event in consecutive treatment guidelines. These NNT were compared to those that patients considered would justify taking a daily medicine.

Data on NNT acceptability is based on the systematic review of...
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Byrne et al.¹ study the impact of changing clinical guidelines for statin therapy in relation to the primary prevention of cardiovascular disease (CVD). The authors calculated numbers needed to treat (NNT) to prevent a major vascular event in consecutive treatment guidelines. These NNT were compared to those that patients considered would justify taking a daily medicine.

Data on NNT acceptability is based on the systematic review of Albarqouni et al.² who find that 60% of participants in included studies would consider taking daily medication preventative of CVD with NNT>30, and 71% with NNT <30. Contrary to this evidence, Byrne et al. take the latter figure, and assume that NNT>30 would be unacceptable to patients. The decision to use this sharp cutoff is described as being made “for illustrative purposes only”. This critical qualification is mentioned in these terms only once more.
Unsurprisingly, if a sharp threshold for unacceptability is imposed by assumption, much unacceptability is observed. However, this arbitrary threshold for acceptability does not seem to influence strong conclusions made elsewhere, e.g. “for many of the individuals, the reduction in risk of cardiovascular events would not be large enough to justify taking a daily medication”. The requisite nuances of interpretation have, with some predictability, escaped media reporting on this work (e.g.³), with claims that “thousands could be taking statins for no reason”.

The decision to use NNT rather than absolute risk reduction or other measures of risk adds to the challenges of interpretation. The companion overview of systematic reviews published by members of this author group⁴recommends that patient decisions to use statins be informed, amongst other considerations, by absolute risk reductions (data on patient acceptability of which is available in Albarqouni et al. There is evidence⁵that patients better comprehend risks when these risks are presented using methods other than NNT for a number of reasons, including that patients seem to better comprehend probabilities using absolute or relative risk reductions, the challenges of calculating uncertainty for NNT, and interpretations by patients that NNT communicates the risk to others rather than their own risk.

References
1. Byrne P, Cullinan J, Gillespie P, Perera R, Smith SM. Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort. Br J Gen Pract 2019: bjgp19X702701.
2. Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart 2017; 103(20):1578.
3. Blanchard S. Thousands 'could be taking statins for no reason' as 600% MORE people are eligible than 30 years ago but prescribing is less efficient. Daily Mail. 2019.
4. Byrne P, Cullinan J, Smith A, Smith SM. Statins for the primary prevention of cardiovascular disease: an overview of systematic reviews. BMJ Open 2019; 9(4): e023085.
5. Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-Based Risk Communication: A Systematic ReviewEvidence-Based Risk Communication. Ann Intern Med 2014; 161(4):270-80.

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Competing Interests: None declared.

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