In a new Annals ‘Beyond the Guidelines’ feature, a preventive cardiologist and a general internist discuss their approach to the use of statins for primary prevention of cardiovascular disease (CVD) and how they would apply the guidelines to an individual patient. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

CVD is the leading cause of death in the United States.  In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. One strategy to identify candidates for statins is to estimate the 10-year risk for CVD using a validated risk calculator. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans have each proposed an approach to the use of statins in primary prevention of CVD, which differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin.

BIDMC Grand Rounds discussants, Mark D. Benson, MD, PhD, a preventive cardiologist, and Stephen P. Juraschek, MD, PhD, a general internist recently discussed the case of a 57-year-old woman with high cholesterol and a family history of heart disease. She is interested in being treated with statins.

In his assessment, Dr. Benson would discuss clinical risk-enhancing factors with patients who are at intermediate risk or otherwise have a borderline indication to begin taking a statin in order to help recalibrate risk estimates if needed. Dr. Juraschek places less emphasis on the use of risk-enhancing factors to refine the 10-year CVD risk estimate provided by the PCE calculator. He also  recommends coronary artery calcium (CAC) testing for patients with borderline risk or low risk with risk-enhancing factors, while Dr. Benson feels that CAC testing can refine risk estimates in patients with borderline or intermediate risk but points out that this advanced testing has important limitations. Dr. Benson supports the VA recommendations to focus on the intensity of statin use rather than to titrate to a particular LDL cholesterol target. However, Dr. Juraschek recommends LDL cholesterol measurement after initiation of a statin, to ensure the patient is taking it, and because it guides the additoin of other lipid-lowering agents in some patients. Both clinicians emphasize the important of shared decision making when counseling patients.