Potential for Net Benefit Should Guide Preventive Therapy
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Opposing Viewpoint, see p 627
Soren and Durrington propose calculating the number needed to treat (NNT) to prevent 1 cardiovascular event to guide primary prevention statin initiation.1 NNT varies depending on the levels of baseline low-density lipoprotein cholesterol (LDL-C) and absolute atherosclerotic cardiovascular disease (ASCVD) risk. We agree with Soran and colleagues1 that baseline LDL-C is an important consideration when deciding when to initiate statin therapy for primary prevention. They stated, “The results of our calculation of number needed to treat (NNT)s provide clear support for abolishing the low density lipoprotein cholesterol (LDL-C) goals for statin treatment in people with lower pretreatment LDL levels, but high CVD risk.”1
We disagree with their next statement: “However, people with more marked hypercholesterolaemia derive more benefit from treatment aimed at specific LDL-C targets.”1 The 2013 American Heart Association/American College of Cardiology 2013 cholesterol guideline (2013 Guideline) recommended that those people with marked hypercholesterolemia be treated with maximally tolerated LDL-C-lowering therapy proven to provide “net benefit” in randomized controlled trials.2
The 2013 Guideline moved toward risk-based decision making. Increased ASCVD risk was necessary, but not sufficient, to receive a recommendation for LDL-C-lowering drug therapy. Three high-risk groups were identified based on strong evidence for net benefit from statins: individuals with clinical ASCVD, those with primary untreated LDL-C ≥190 mg/dL, and those with diabetes …