Author + information
- Martin Bødtker Mortensen, MD, PhD,
- Shoaib Afzal, MD, PhD,
- Børge G. Nordestgaard, MD, DMSc∗ ( and )
- Erling Falk, MD, DMS
- ↵∗Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark
We thank Dr. Kain for commenting on our recent paper on risk-based versus trial-based approaches to guide statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) (1). We naturally agree that indiscriminate use of statins should be avoided, not only in South Asians, but also in other ethnic and racial groups, due to both the cost and possible side effects. In primary prevention particularly, the benefit of treatment should significantly exceed possible harm of treatment. We also agree that statin-induced side effects may be more prevalent in some ethnic and racial subgroups due to genetically determined differences in statin metabolism.
This is yet another reason for matching the eligibility for and intensity of statin therapy to the patient’s absolute risk for future ASCVD, as recommended by current guidelines on ASCVD prevention. In such a risk-based approach, absolute ASCVD risk can be used to balance the expected benefit of statins against potential risk of harm. In contrast to a trial-based approach in which the cutoff for initiating statin therapy is given a priori by enrollment criteria used in randomized controlled trials, the cutoff for initiating statin therapy in a risk-based approach can be modified in specific ethnic/racial subpopulations if the side effects prove to be more frequent, to ensure that benefit continues to outweigh potential harm.
That being said, statins are among the most extensively studied drugs with regard to both their efficacy and safety (2,3). Statins are generally well tolerated and effective in reducing the risk of ASCVD in various populations, and no available data suggest that statins are less efficient in specific racial or ethnic groups. The MEGA (Management of Elevated Cholesterol in the Primary Prevention of Adult Japanese) trial (4) provided evidence that statins also effectively reduced risk of ASCVD in Asian populations, similarly to that observed in white populations (2).
Importantly, in our study of whites, the risk-based approach recommended by the American College of Cardiology and the American Heart Association prevented more ASCVD events than the trial-based approach, by treating fewer individuals (1). We are not aware of data to suggest that this conclusion could not be applied equally to South Asians or other racial groups.
Please note: This work was supported by Herlev and Gentofte Hospital, Copenhagen University Hospital, the Copenhagen County Foundation, and Aarhus University, all from Denmark. The funding organizations had no role in any of the following: design and conduct of the study, in collection, analysis, and interpretation of the data, and in the preparation, review, or approval of the manuscript. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation