Heartbeat: Challenges in primary prevention of cardiovascular disease.

In addition to encouraging a healthy lifestyle and treating modifiable risk factors, one of the mainstays for primary prevention of cardiovascular disease (CVD) is the use of statin therapy in people with increased CVD risk. However, it is confusing for clinicians and patients that guidelines from different organisations make different recommendations about who to treat and how to set treatment goals.1 In my editorial in this issue of Heart, the 3 major differences between guidelines are summarised: (1) how CVD risk is calculated, (2) the risk threshold for recommending statin therapy and (3) the use of treatment with a fixed statin dose versus therapy adjusted to achieve a serum low density lipoprotein (LDL) target. The rationale for different risk scores in each guideline is because CVD risk prediction varies in different populations; ideally the risk score was derived from the population being treated. Evidence suggests that statin therapy is beneficial even for lower risk patients; thus, the threshold chosen for treatment depends on estimates of the likelihood (and acceptance) of side effects, as well as cost considerations. The decision to recommend fixed dose versus LDL level targeted therapy is primarily an economic decision given that more intensive treatment requires more monitoring and may increase risk. The UK National Institute for Health and Care Excellence (NICE) guidelines recommend offering fixed dose atorvastatin 20 mg to people whose 10-year risk of developing cardiovascular disease is ≥10% using the QRISK assessment tool, which includes all patients over age 84 years. Another approach to primary prevention of CVD is the use of a single pill that includes a statin and antihypertensive agents given to entire populations, an approach known as the ‘polypill’. In a microsimulation model, Ferket and colleagues2 found that the optimal strategy for this approach was treatment with the polypill when 10-year CVD risk was greater than 20%. This approach was predicted to gain 123 quality adjusted life years (QALYs) per 10K individuals at an extra cost of £1.45 million.