By Austin Ulrich, PharmD, BCACP

Clinical Pharmacist Practitioner, UpStream Pharmaceutical Care, Greensboro, NC

SYNOPSIS: Researchers weighed patient preferences and risks regarding statin therapy after reviewing 10-year atherosclerotic cardiovascular disease risk scores.

SOURCE: Brodney S, Valentine KD, Sepucha K, et al. Patient preference distribution for use of statin therapy. JAMA Netw Open 2021;4:e210661.

The American College of Cardiology/American Heart Association, U.S. Preventive Services Task Force, and the U.S. Department of Veterans Affairs/Department of Defense Health Care Systems clinical guidelines provide clear recommendations for statin therapy as primary atherosclerotic cardiovascular disease (ASCVD) prevention for certain groups.1-3 Despite these recommendations favoring statin treatment for patients at risk for CVD, only about one-third of eligible patients take statins.4 Although the guidelines all include similar stratification of risk thresholds, they differ in the exact thresholds established. Historically, one suggestion to improve clinical guideline recommendations has been to incorporate patient preference into guideline development, although this rarely is the case.5

To determine the feasibility of using patient preference for statin therapy in establishing ASCVD risk thresholds, Brodney et al conducted a “survey study” to determine preferences for statin therapy. Patients included in the study were not taking a statin or proprotein convertase subtilisin/kexin type 9 inhibitor for primary prevention. Participants entered their age, sex, cholesterol levels, blood pressure, hypertension treatment, diabetes status, and smoking status to determine their 10-year ASCVD risk scores. They also received a description of the benefits and possible adverse effects of statins.

There were 304 participants in the final survey sample, with an average age of 54.8 years. In total, 137 patients indicated they would choose to take a statin (26 answered “definitely take” and 111 answered “probably take”). The remaining 167 patients indicated they would not choose to take a statin (91 answered “probably not take” and 76 answered “definitely not take”). When participants were asked about taking a statin across various ASCVD risk levels, they were more likely to choose statin therapy as risk levels increased (54.7% at ≥ 5% risk to 81.1% at ≥ 25% risk). Statin preferences were partially dependent on whether a healthcare provider had talked to the participant about statin therapy. There was a significant increase in patients who would choose to take a statin if they had engaged in a discussion. Interestingly, patients with better health literacy, higher subjective numeracy scores, and higher knowledge scores were significantly less likely to want statin therapy.

The authors concluded there is not a specific CV risk threshold for which shared decision-making should be applied to initiate statin therapy. Rather, shared decision-making could be applied to a wide range of CVD risk scores.

COMMENTARY

In this study, no ASCVD risk level reached the recommended 95%-99% threshold where patient preference could inform guideline recommendations.5 However, this was a fairly small sample size, and many patients who are otherwise eligible for statin therapy already are taking a statin. This selection bias was a major limitation of this study and may underestimate the true proportion of patients who would take a statin, since patients already taking a statin likely would choose to stay on statin therapy in this survey study setting. Additionally, the way the risks (denominator of 1,000) and benefits (denominator of 100) were presented could have falsely skewed patients’ perceptions to be less favorable toward statins. Internal medicine and other primary care practitioners frequently experience resistance from patients about taking statins. Although it is helpful to take patients’ preferences into consideration and engage in shared decision-making, clinicians should present their patients with accurate information and evidence-based recommendations about statin use for optimal outcomes and to promote patient engagement. 

REFERENCES

  1. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;140:e596-e646.
  2. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA 2016;316:1997-2007.
  3. O’Malley PG, Arnold MJ, Kelley C, et al. Management of dyslipidemia for cardiovascular disease risk reduction: Synopsis of the 2020 updated U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med 2020;173:822-829.
  4. Colantonio LD, Rosenson RS, Deng L, et al. Adherence to statin therapy among US adults between 2007 and 2014. J Am Heart Assoc 2019;8:e010376.
  5. Eddy DM. Clinical decision making: From theory to practice. Designing a practice policy. Standards, guidelines, and options. JAMA 1990;263:3077, 3081, 3084.