John Downs, MD; Chester Good, MD, MPH
Note: Drs. Downs and Good are members of the Medical Advisory Panel for Pharmacy Benefits Management, Department of Veterans Affairs.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2850.
Requests for Single Reprints: John Downs, MD, South Texas Veterans Health Care System, Medicine Service (111), 7400 Merton Minter, San Antonio, TX 78229; e-mail, email@example.com.
Current Author Addresses: Dr. Downs: South Texas Veterans Health Care System, Medicine Service (111), 7400 Merton Minter, San Antonio, TX 78229.
Dr. Good: Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive C, Pittsburgh, PA 15240.
Author Contributions: Conception and design: J. Downs, C. Good.
Drafting of the article: J. Downs, C. Good.
Critical revision of the article for important intellectual content: J. Downs, C. Good.
Final approval of the article: J. Downs, C. Good.
Administrative, technical, or logistic support: J. Downs.
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Brian S Alper, Alan Drabkin
EBSCO Information Services, DynaMed
March 21, 2014
Conflict of Interest:
Drs. Alper and Drabkin both work full-time for EBSCO Information Services which publishes DynaMed. Neither have any conflicts of interests related to statins or the content of this comment.
Statin guidelines and Number Needed to Treat
The threshold for recommending statin therapy for primary prevention is a current controversy. The threshold of estimated 10-year risk of cardiovascular disease (CVD) for beginning therapy varies from ≥ 7.5% in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline (1) to ≥ 20% in the current United Kingdom National Institute of Health and Care Excellence (NICE) guideline (2). Recent Opinions articles (3,4) suggest a threshold of ≥ 15% may be more appropriate. Downs and Good (3) also note that “the number needed to treat to prevent a clinically relevant cardiac event” is an important concept for individual decision-making with patient-specific information on the benefits and risks of choosing statins or not for primary prevention.We estimated the number needed to treat (NNT) for preventing major outcomes for various levels of estimated 10-year risks (5). We used data from the most current and reliable systematic reviews available for estimating these effects. Our estimates used 5-year NNT to match a timeframe easier for patients to relate to and to better match the available data. For a person with an estimated 10-year CVD risk of 5%, the NNT to prevent an event over 5 years was 160 for CVD events, 278 for myocardial infarction (MI), and 910 for stroke. For a person with an estimated 7.5% 10-year risk, the 5-year NNT was 108 for CVD events, 186 for MI, and 606 for stroke. At 10% 10-year risk, 5-year NNTs were 80 for CVD events, 140 for MI, and 456 for stroke. Mortality was not significantly reduced at risk levels 10% and lower. At 15% 10-year risk, 5-year NNTs were 54 for CVD events, 94 for MI, 204 for stroke, and 334 for overall mortality. At 20% 10-year risk, 5-year NNTs were 40 for CVD events, 70 for MI, 228 for stroke, and 250 for overall mortality. (We can also provide this data as a table)Clinicians and patients can use this information during the process of decision making, and it would be useful to incorporate into decision aids Yours sincerely,Brain S. Alper, MD, MSPH, FAAFPFounder of DynaMedVice President of Evidence-Based Medicine Research and Development, Quality and StandardsEBSCO Information ServicesAlan Drabkin, MDSenior Clinical WriterDynaMedEBSCO Information Services References.1. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol [Internet]. 2013 Nov 7. [Epub ahead of print]2. Cooper A, Nherera L, Calvert N, O’Flynn N, Turnbull N, Robson J, et al. Clinical Guidelines and Evidence Review for LipidModification: cardiovascular risk assessment and the primary and secondary prevention of cardiovascular disease [Internet]. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2008 [cited 2014 Mar 17]. Available from http://www.nice.org.uk/nicemedia/live/11982/40742/40742.pdf: 3. Downs J, Good C. New Cholesterol Guidelines: Has Godot Finally Arrived?. Ann Intern Med. 2014 Mar;160(5):354-355.4. Martin SS, Blumenthal RS. Concepts and Controversies: The 2013 American College of Cardiology/ American Heart Association Risk Assessment and Cholesterol Treatment Guidelines. Ann Intern Med. 2014 Mar;160(5):356-358-358. 5. DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – .Record No. 115052, Statins for prevention of cardiovascular disease; [updated 2014 Mar 17; cited 2014 Mar 17]; [about 56 screens].Available from http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=115052&site=dynamed-live&scope=site Registration and login required.
Downs J, Good C. New Cholesterol Guidelines: Has Godot Finally Arrived?. Ann Intern Med. 2014;160:354–355. doi: 10.7326/M13-2850
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Published: Ann Intern Med. 2014;160(5):354-355.
Cardiology, Coronary Risk Factors, Dyslipidemia.
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