This week’s paper of the week is brought to you by Professor Sir Muir Gray, 3V’s Founding Director.
Bottom line, chosen by Muir from the paper
Statin therapy has been shown to reduce major vascular events and vascular mortality in a wide range of individuals, but there is uncertainty about its efficacy and safety among older people… Statin therapy produces significant reductions in major vascular events irrespective of age, but there is less direct evidence of benefit among patients older than 75 years who do not already have evidence of occlusive vascular disease. This limitation is now being addressed by further trials.
Implications for value improvement
Few issues illustrate the difficulty in making value based decisions about conditions that do not have a clear difference from normal than hypercholesterolaemia. You either have lung cancer or you do not but everyone has a cholesterol level. There is no dispute that people who are at high risk of a heart attack benefit from statins; they are effective and cost effective but as the risk of heart disease reduces the balance between benefits and harms, changes exactly following the classic Donabedian curve.
It is clear that giving statins to people at high risk is high value but would a policy to give people over 75 statins be at point A or point B on the curve:
The answer is “now being addressed by further trials” but probably there will never be a clear answer.
Another impressive study in the Lancet emphasises the need to take other risk factors such as ethnicity and deprivation into account (1). It may be that Augmented Intelligence, a better interpretation of the term AI than Artificial Intelligence, may help individuals in groups near the point of optimality make a decision on whether or not to take a statin.
However, it is unlikely AI will solve this dilemma and as the accompanying editorial to the Lancet paper on the over 75’s titled – ‘never too old for statin treatment’ emphasises
‘The challenge for the health-care profession and the media is to convey risks and benefits in ways that
patients can understand, enabling them to make an informed choice.” (2)
References:
- Pylypchuk R. et al (2018) Cardiovascular risk prediction equations in 400,000 primary care patients in New Zealand. Lancet 391;1897-1907
- Bernard M Y Cheung, Karen S L Lam (2019) Never too old for statin treatment? Lancet 393 379-380