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  • Review Article
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Statins in the primary prevention of cardiovascular disease

Nature Reviews Cardiology volume 10, pages 453–464 (2013)Cite this article

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Abstract

Statins are widely used in the evidence-based lowering of cardiovascular disease (CVD) risk. The use of these drugs for secondary prevention of CVD is well founded, but their expanding use in primary prevention—in individuals without documented CVD—has raised some concerns. Firstly, evidence suggests that, in primary prevention, statins substantially decrease CVD morbidity, but only moderately reduce CVD mortality. Secondly, long-term statin use might cause adverse effects, such as incident diabetes mellitus. Thirdly, the cost-effectiveness of such a strategy is unclear, and has to be balanced against the risk of 'overmedicating' the general population. Data clearly support the use of statins for primary prevention in high-risk individuals, in whom the strategy is cost-effective and the benefits exceed the risks. Whether primary prevention is beneficial in individuals at low or moderate risk is not certain. Therefore, the prescription of statins for primary prevention should be individualized on the basis of clinical judgment, particularly for low-risk individuals. In appropriately selected individuals, statins should also be used for primary prevention of ischaemic stroke and transient ischaemic attack.

Key Points

  • Large clinical trials and meta-analyses suggest that lowering the LDL-cholesterol level with statins in primary prevention modestly reduces all-cause mortality and substantially decreases the rate of cardiovascular events

  • Statins are recommended for primary prevention in nearly all high-risk individuals, whereas an individualized approach is recommended in those at moderate or low risk

  • Statins should be used for primary prevention of cardiovascular disease in women in the same manner as in men

  • Statins reduce cardiovascular risk when used for primary prevention in elderly individuals, but their use, particularly in high doses, requires clinical judgment and an individualized approach

  • Statins should be used for primary prevention of ischaemic stroke and transient ischaemic attack, at least in appropriately selected individuals

  • Low-cost, generic forms of statins are particularly cost-effective for primary prevention, especially in high-risk individuals

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Figure 1: Effects on vascular and nonvascular deaths per 1.0 mmol/l reduction in the LDL-cholesterol level with statin use, according to level of 5-year MVE risk.
Figure 2: Possible mechanisms to explain the aetiology of statin-induced myopathy.
Figure 3: Association between reduction in LDL-cholesterol concentration and incidence of stroke in major statin trials.

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  1. Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia

    Željko Reiner

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The author declares that he has received honoraria from the following companies: Abbot, AstraZeneca, Bayer, and Sanofi.

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Reiner, Ž. Statins in the primary prevention of cardiovascular disease. Nat Rev Cardiol 10, 453–464 (2013). https://doi.org/10.1038/nrcardio.2013.80

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