Opinion
Video
Weighing the Benefits and Risks of Statin Therapy
Author(s):
Panelists discuss how statin therapy for primary prevention requires careful consideration of cardiovascular risk factors against potential adverse effects such as myalgia and liver abnormalities, generally favoring treatment when the calculated 10-year atherosclerotic cardiovascular disease [ASCVD] risk exceeds 7.5% to10% and adjusting recommendations based on individual patient factors including age, comorbidities, and preferences.
Weighing Benefits and Risks of Statin Therapy for Primary Prevention
Clinical Decision-Making Framework
Statin therapy for primary prevention requires careful consideration of potential cardiovascular benefits and risks of adverse effects. The decision should be individualized based on the following:
- Patient's absolute cardiovascular risk (using validated risk calculators)
- Potential benefit magnitude vs likelihood of adverse effects
- Patient preferences and values
Risk Assessment Considerations
- High benefit likelihood: Patients with LDL-C levels greater than or equal to 190 mg/dL, diabetes, or 10-year ASCVD risk greater than or equal to 7.5%
- Moderate benefit: 10-year ASCVD risk between 5% and 7.5%
- Lower benefit: 10-year ASCVD risk less than 5%
Risk-Benefit Inflection Points
Consider initiating statins when:
- 10-year ASCVD risk is greater than or equal to 7.5% (strong recommendation)
- 10-year ASCVD risk is between 5% and 7.5% (consider based on risk enhancers)
- Presence of significant risk enhancers even with lower calculated risk
Managing Adverse Effects
- Muscle symptoms: Present in 5% to 10% of patients; often mild and manageable
- Liver abnormalities: Clinically significant hepatotoxicity rare (less than 0.1%)
- New-onset diabetes: Small absolute risk increase (0.1% to 0.3% per year)
Practical Approach
- Discuss absolute risk reduction with patients in understandable terms
- Consider alternative dosing strategies for statin-intolerant patients
- Schedule follow-up to assess tolerability at 4 to 12 weeks
- Reevaluate benefit-risk balance periodically, especially with advancing age
Patient Engagement
Shared decision-making should incorporate patient preferences regarding medication burden, health priorities, and risk tolerance with clinical recommendations.
