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Statins, risk, and personalised care

BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-076774 (Published 18 March 2024) Cite this as: BMJ 2024;384:e076774
  1. Sam Finnikin, general practitioner1,
  2. Brian Finney, lay contributor,2,
  3. Rani Khatib, associate professor34,
  4. James McCormack, professor5
  1. 1Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
  2. 2Patient author, Merseyside, UK
  3. 3Leeds Teaching Hospitals NHS Trust, Leeds, UK
  4. 4University of Leeds, Leeds, UK
  5. 5Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
  1. Correspondence to: S Finnikin s.j.finnikin{at}bham.ac.uk

Sam Finnikin and colleagues argue that guidelines should focus less on population level risk thresholds and more on shared decision making conversations based on individualised risk and patient preferences

Statins are the most prescribed medications in England with over 82 million prescriptions issued in the 12 months to July 2023.1 However, the 2023 update of guidelines from the UK National Institute for Health and Care Excellence (NICE) suggested that they could now be given to millions more people with lower risk scores.2 The recommendations raised concerns about the reduced benefit for lower risk patients and extra workload for general practitioners, who already spend considerable amounts of their time managing risk of cardiovascular disease (CVD).3 A change of emphasis is needed to achieve the overall goal of helping people make healthcare decisions based on effective risk communication, holistic care, and shared decisions.

Cardiovascular risk estimation is fundamental to prescribing guidelines

Statins have consistently been shown to reduce the risk of CVD,4 and greater use of statins at a population level could be a cost effective and clinically effective way of reducing the disease burden. However, the benefits of statins for otherwise healthy individuals are relatively small and, at an individual level, for many people, the benefits may not outweigh the potential harms.5 To balance underuse and overuse international guidelines have, for many years, recommended using estimated cardiovascular risk to guide treatment recommendations. For example, the US Preventive Services Task Force and NICE use a 10 year risk threshold of 10%,26 whereas the World Health Organization uses 20%7 and the European Society of Cardiology use risk categories combined with lipid levels.8

Risk factors for CVD such as age, sex, blood pressure, and lipid concentrations are well established and can be used to estimate risk relatively quickly for most people without existing …

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