Who needs to be on a statin?

There are several categories of people who should automatically be on statins:

  • people who have had a cardiovascular event: MI, CVA/TIA, PVD, CVD. They need statins even if their cholesterol levels are normal.
  • people who have an LDL >190 on two separate occasions. Be sure to rule out thyroid dysfunction, nephrotic syndrome, and ingestion of coconut and palm oil, which can affect cholesterol measurements.
  • type II diabetics, especially those with hypertension or who are smokers

What to make of risk calculators? First of all, DON’T use the Framingham score alone–there are better options out there. ACC/AHA is good as a calculator that measures the risk of future MI or CVA, but there are some issues with the fine-tuning of that calculator, so the UK JBS is a good second calculator to compare. The real answer is probably going to be somewhere between those two.

How can you logically figure out who should be on statins? By comparing absolute benefit with absolute risk.

Absolute benefit=patient risk x relative risk reduction in the literature, which for statins, turns out to be [patient’s risk determined by risk calculator] x [0.25]. There’s a lot of math that goes into that 0.25. If you’re interested, look up PICO–here’s an example.

For statins, there is a 1-3% risk of developing diabetes, so that is the absolute risk.

So the final calculation is: (patient risk x 0.25) compared to 1-3%.

What statin should you start people on? In my very limited experience, atorvastatin 20-40 mg is a good place to start (for post-MI patients, atorvastatin 80 mg seems to be the standard). Rosuvastatin is another good option, although may be more expensive? Simvastatin is most frequently associated with myalgias and drug interactions, such as with calcium channel blockers, and is used less frequently.

See also: When should statins be STOPPED?

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