Ischaemic heart disease

Many Australians getting suboptimal statin doses

Higher statin doses translate into a larger survival benefit for people with pre-existing heart disease, a real-world study shows, but an overemphasis on side effects means many Australians may be receiving suboptimal doses, an expert says.

The National Heart Foundation’s chief medical advisor, Professor Garry Jennings was commenting on a US study in just over half a million Americans aged 21 to 84 years that showed there was ‘substantial’ opportunity to improve secondary prevention of atherosclerotic cardiovascular disease (ASCVD) by upping statin intensity in more people with the condition – including those aged over 75.

The study authors from Stanford University found a consistent, graded association between intensity of statin therapy and mortality, with the greatest reductions seen in patients receiving high-intensity statins.

They also found the maximal doses of high-intensity statins (atorvastatin, 80 mg, and rosuvastatin, 40 mg) conferred the greatest survival advantage compared with submaximal doses of high intensity statins.

Over the 12-month follow up 4% of those receiving high-intensity statins died, compared to 4.8 per cent of people on moderate doses, 5.7 per cent on low doses and 6.6 of those receiving no statins.

And, the same survival benefit was seen in patients over the age of 75, a group little studied in clinical trials

Talking to the limbic, Professor Garry Jennings said the new findings were ‘broadly consistent’ with consensus here in Australia.

“The US moved away from targets for LDL a few years ago while we have not and neither have the Europeans but certainly our targets have been shifting progressively lower with time,” he said.

“Current Australian ACS guidelines say to target levels at 1.8 mmol/l but there’s a push for even lower targets based on findings from the PROVE-IT study to go for targets as low as 1.4 – and that means higher doses of the strongest statin you can find.”

But he agreed that, in practice, there are likely many patients being prescribed statins at suboptimal doses.

“Its quite common in Australia to recommend the highest tolerated dose – you stop if someone’s getting side effects but otherwise keep going to the maximum tolerated level – but that’s not necessarily happening in practice and there are probably a high number of patients not getting the best dose that they could handle.”

He also said that he believes there has been an overemphasis on the side effects of statins and under stating of their benefits.

“By over emphasising the side effects of statins we are probably denying people the possibility of avoiding a heart attack or stroke, which is probably more valuable to them than a few aches and pains

The authors said their findings support the notion that physicians should prescribe the maximally tolerated doses of atorvastatin or rosuvastatin for patients with ASCVD.

However Professor Jennings said he’d be cautious about high intensity statins in patients over the age of 75 for now.

“In Australia we are running randomised controlled trials specifically looking at statins in older people and given that we generally consider RCTs to be the gold standard for informing practice, the findings from those studies that should settle questions about older patients,” he said.

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