When to Start a Statin Is a Preference-Sensitive Decision
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Article, see p 1087
In this issue of Circulation, Heller et al1 report results of a simulation model suggesting that the American Heart Association/American College of Cardiology (AHA/ACC) primary prevention lipid treatment guidelines treat many more people with a statin but also save many more lives compared with ATP III. These findings are consistent with previous reports,2,3 but their results further suggest that starting a statin at 40 years of age in everyone regardless of cardiovascular disease (CVD) risk would extend statin treatment to >28 million more Americans but would further and substantially improve the public’s health, but only if the disutility associated with pill burden is quite low.
Public Versus Individual Decisions
If starting a statin in all adults at 40 years of age would really save hundreds of thousands of quality-adjusted life years (QALYs), implementing such a policy would seem to be a public health priority. However, this perspective has several problems. Principally, taking a statin is an individual not a public health decision, such as interventions to improve air quality or a decision with externalities, such as treating contagious diseases. For an individual decision without externalities, an individual’s chance and magnitude of net benefit (absolute risk reduction minus absolute risk increase plus/minus uncertainties) is the only meaningful consideration.4 This may sound heretical, especially coming from a professor of public health, but the ethical and legal standards are clear. When counseling an individual patient about treatment, the most relevant question is almost always, “What is the magnitude of and uncertainty bounds for estimated net benefit for the considered treatment?” Heller et al1 present a relevant estimate in this regard. If their base-case estimates are correct, adoption of the treat at 40 years of age policy, compared with AHA/ACC guidelines, would average 1 additional QALY gained …