Statins for all?

Recent guidelines for cholesterol management proposed by the American College of Cardiology (ACC) and American Heart Association (AHA) recommended statin therapy for most men in their 60s and most women in their 70s. If these guidelines are followed in the United States, most adults will eventually take statins. A companion article in this journal goes a step further by proposing statin initiation for mostly everyone about 10 years earlier. Treatment in ACC/AHA guidelines does not depend on cholesterol levels, for either statin initiation or treatment goals. Selection of patients for statin therapy depends instead on multifactorial risk assessment derived from prospective studies in subgroups of the US population. Because of expansion of statin therapy, the issue of the reliability of risk assessment has come to the fore. Some evidence suggests that the ACC/AHA risk algorithm overestimates risk in many persons; if so, this would lead to statin therapy beyond what was intended. Some investigators favor assessment of risk based on presence or absence of categorical risk factors or higher risk conditions. Others propose selection of individuals for statin therapy grounded in measurement of atherosclerosis burden. Finally, an alternate approach to cholesterol management is to establish cholesterol goals for secondary and primary prevention. Cholesterol levels, and not global risk assessment, here define the intensity of therapy. The use of cholesterol goals allows more flexibility in treatment by taking advantage of lifestyle therapies and various drugs and their doses to attain defined goals.