Heart 2006 May 22; (Read article online)

McElduff P, Jaefarnezhad M, Durrington PN

Objective To compare national and international recommendations for statin treatment in the primary prevention of cardiovascular disease in middle aged men. Design Application of the current American, British and European recommendations to results of a prospective study. Participants Men aged 49-65 years (n=1653), who participated in the Caerphilly Prospective Study. Main outcome measures Proportion who would receive statin treatment, the number needed to treat (NNT) to prevent one first cardiovascular (CVD) event (myocardial infarction and stroke) over 10 years and the potential number of events prevented over 10 years in the whole population (population impact) by the use of statins in accordance with each set of guidelines, assuming a reduction of risk in the range 10-50% using the observed events and base-line risk factors. Results There were 212 events. For an anticipated reduction in first CVD events of 30% with statin treatment, the NNT was 26.0, if the whole population was treated. The lowest NNT was 12.1 for the National Health Service Framework (NSF), achieved when only 14% of the men received a statin. However, this prevented the lowest number of events (19.2/212) and had the smallest population impact on CVD incidence (-9.1%). The American and earlier Joint British Societies guidelines, although giving NNT's of around 21 prevented more events and had a greater population impact of -21.6 to - 23.3%. They did, however, target some 60% of the male population. The British Hypertension Society guidelines and new Joint British Societies recommendations achieved the greatest population impact of -27% whilst maintaining the NNT at 22.2. They did, however, target three quarters of this population. Conclusion Even effective preventive therapy will have little impact in preventing disease if its deployment does not include those at typical risk. Whether cholesterol-lowering on such a scale should be attempted with medication raises philosophical, psychological and economic considerations, particularly in view of the high likelihood of individual benefit from statin treatment. More effective nutritional policies to reduce serum cholesterol on a population level and reduce the requirement statins in primary prevention should also be considered.