The authors of this research letter write to acknowledge their disagreement with a recent editorial comment in the Archives of Internal Medicine that listed statins for patients without coronary artery disease as an example of the “widespread use of medications with known adverse effects despite the absence of data for patient benefit”. 

They say that they disagree with a ‘less is more’ approach when it comes to statins for primary prevention of cardiovascular disease (CVD), and believe that there is compelling evidence to support their use in patients at high risk (Framingham risk score >10%) for developing coronary heart disease (CHD) over the next 10 years.  The argument made in the editorial was based on the assertion that statin therapy has no near-term (<5-year) benefit on all-cause mortality but the authors of this research letter question whether any intervention would be expected to, in an asymptomatic individual.  They go on to summarise the all-cause mortality data for statin therapy in primary prevention (discussing three meta-analyses; two of which found a modest but statistically significant reduction in all-cause mortality), and the data on cardiovascular morbidity.

The authors conclude that statins are unlikely to benefit patients with a low coronary risk (10-year Framingham risk score, <10%), but that patients without known CHD but with diabetes, hypertension, hyperlipidaemia and tobacco use are at increased risk for developing CHD and are likely to benefit from statin primary prevention in accord with ATP III guidelines.

An Editor’s note accompanying this article, written by the authors of the original editorial comment, notes how the authors of the research letter used a meta-analysis of both primary and secondary prevention to support their arguments, and how the majority of the benefit seen in this analysis occurred in the studies of secondary prevention.  They note also that the research letter fails to acknowledge the commonly reported side-effects reported with statins, and comment that: “For a medicine to be recommended to healthy patients for a lifetime of use, there should be robust evidence that this regime will reduce suffering or extend life, and evidence that the benefit outweighs adverse effects. Until there is such data for statins for primary prevention, we will continue to classify it as an intervention without known benefit, but with definite risks, in our Less Is More series.”