The role of statins in primary pevention of cardiovascular disease

Guidance on statin provision in patients without cardiovascular disease is of great practical importance. In recent years, several publications emerged showing conflicting results. The systematic review by Thavendiranathan et al. is timely and covers a relevant issue but not without limitations. We have 3 observations. First, this review enrolled moderate- and high-risk patients (average extrapolated 10-year coronary risk, 13%) despite the fact that greater than 80% of the US population who are free of cardiovascular disease do not fall into this risk category. No direct conclusions of the effects in this large group can therefore be made. Second, it is unclear how the authors reached the conclusion that “reductions in the risk of major coronary events from statin therapy were significantly associated with greater absolute baseline coronary artery disease risk.” We were unable to reproduce this finding when repeating analyses using the data presented in Tables 1 and 2 in the review by Thavendiranathan et al. We constructed a forest plot sorted for increasing baseline risk of the primary studies showing an inverse association. A greater (relative) benefit from statin therapy was significantly associated with smaller absolute baseline risk for major coronary events (P = .04). Third, regarding the number-needed-to-treat analyses, it seems inconsistent that the authors assumed the effects of statins to be constant across risk groups, an assumption contradictory to their metaregression analysis