Statins as first-line therapy

Statins are the first-line therapy for both primary and secondary prevention. Meta-analysis of the numerous large clinical trials concluded that statin therapy results in a 22 per cent relative risk reduction of major cardiovascular events with each 1mmol/L drop in LDL-C. NICE recommend prescribing a statin that will result in a reduction in LDL-C (or non-HDL-C) of at least 40 per cent.

Atorvastatin 20mg once per day is recommended as the first-line option for all primary prevention indications. For secondary prevention, a high-intensity, high-potency statin is the first-line option with atorvastatin 80mg once per day recommended, unless there is a high risk of adverse effects, potential drug interactions, patient preference, or CKD (where 20mg is recommended as the starting dose).

Rosuvastatin offers a cost-effective alternative (with the caveat of a starting dose of 5mg once per day and maximum dosage of 20mg once per day in patients of Asian ethnicity).

Recognition that in England only 82 per cent of people with established CVD are prescribed statins (or alternative lipid lowering therapy) and that, even if prescribed, less than 30 per cent of people are treated to target, has led to the introduction of primary care targets to improve lipid management in patients with established CVD (secondary prevention) or chronic kidney disease with Quality Outcomes Framework (QOF) indicators.