Statins for Primary Prevention: the Debate Continues

Several leading cardiologists have taken issue with the assertion made by Rita Redberg and the editors of Archives of Internal Medicine that using statins for primary prevention is an example “of the widespread use of medications with known adverse effects despite the absence of data for patient benefit for these indications.”

In a research letter published in Archives, C. Michael Minder and colleagues (including Sanjay Kaul and Roger Blumenthal) write that they “believe there is compelling evidence to support the use of statins for primary prevention in patients at high risk… for developing coronary heart disease (CHD) over the next 10 years.” They assert that by focusing on short-term mortality the Archives editors overlook the substantial benefits of statin therapy for primary prevention in appropriately selected patients.

Minder and colleagues acknowledge that the evidence for a mortality benefit for statins in primary prevention is “less than robust,” but that when it comes to morbidity the “message is clear.” They cite a Cochrane metaanalysis showing a 34% reduction in revascularizations and a 30% reduction in combined fatal and nonfatal CV endpoints.

The authors argue that it is “paramount to make the distinction between low-risk and high-risk primary prevention cohorts.” They agree that primary prevention is unlikely to benefit people with a 10-year Framingham Risk Score of less than 10%, but that patients “without known CHD but with diabetes, hypertension, hyperlipidemia, and tobacco are likely to benefit from statin primary prevention.”

In response, Redberg and colleagues point out that some of the data in support of primary prevention includes patients with known CHD. Furthermore, they state, the authors “do not acknowledge the commonly reported adverse effects associated with statins, including memory loss, muscle pains, weakness, and liver function abnormalities.”