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Determining optimal threshold for statins prescribing: individualization of statins treatment for primary prevention of cardiovascular disease
Author(s) -
Djulbegovic Benjamin,
Tsalatsanis Athanasios,
Hozo Iztok
Publication year - 2017
Publication title -
journal of evaluation in clinical practice
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.737
H-Index - 73
eISSN - 1365-2753
pISSN - 1356-1294
DOI - 10.1111/jep.12473
Subject(s) - medicine , regret , framingham risk score , statin , disease , framingham heart study , physical therapy , primary prevention , intensive care medicine , machine learning , computer science
Rationale, aims and objectives The A merican C ollege of C ardiology and A merican H eart A ssociation ( ACC / AHA ) statin guidelines recommend that people with risk of cardio‐vascular disease ( CVD ) ≥7.5% over 10 years should be treated with statins. This recommendation ignores individual patient CVD risks and preferences. We compared the ACC / AHA guidelines to the following management strategies a) individualized statins treatment based on F ramingham R isk S core ( FRS ), b) treat none, c) treat all. Methods We employed regret‐based decision curve analysis to evaluate the optimal treatment strategy. We used data on 5013 participants from the second generation of the Framingham Heart Study. We assessed regret of each treatment strategy [treat according to FRS vs. treat none vs. treat all] as a function of emotionally felt loss of treatment benefits and incurred treatment harms. We calculated the difference between regret associated with one strategy compared with the other and expressed it as N et E xpected R egret D ifference ( NERD ). Two strategies are identical if NERD = 0. Results Treatment according to ACC / AHA guidelines represents the optimal strategy only if the patient values avoiding heart disease 12 times more than harms related to statins. For values of benefit/harms ( B / H ) <12, treatment according to FRS represents the optimal strategy. For B / H <3, ‘treat none’ represents equally acceptable strategy. Adopting a threshold of 10% recommended by other professional organizations would decrease over‐treatment by more than 60% without significantly affecting under‐treatment. Conclusion Under most realistic scenarios, individualizing statins treatment, or not recommending statins at all, represents the optimal strategy for primary prevention of heart disease.