Primary prevention of cardiovascular disease with statins: Assessing the evidence base behind clinical guidance

Statins and other cholesterol-lowering drugs are increasingly being used for primary prevention of atherosclerotic cardiovascular disease. Three lines of evidence inform the development of therapeutic goals for both drug and lifestyle intervention. This evidence reveals the following principles for cholesterol lowering in primary prevention: (a) 'the more (lowering), the better' for relative risk reduction, (b) 'the lower, the better' for absolute risk reduction, and (c) 'the earlier, the better' for lifetime risk reduction. From these general axioms, treatment can be adjusted to guide therapies in individual patients. There is no 'one size fits all' for primary prevention and simplicity is not the final word for the management of cholesterol disorders; it is useful but cannot be substituted for clinical judgement.