Recommendations for statin management in primary prevention: disparities among international risk scores

Abstract

Background Statin recommendations in primary prevention depend upon risk algorithms. Moreover, with intermediate risk, risk enhan- and Aims cers and de-enhancers are advocated to aid decisions. The aim of this study was to compare algorithms used in North America and Europe for the identification of patients warranting statin or consideration of risk enhancers and de-enhancers Methods A simulated population (n = 7680) equal in males and females, with/without smoking, aged 45–70 years, total cholesterol 3.5–7.0 mmol/L, high-density lipoprotein cholesterol 0.6–2.2 mmol/L, and systolic blood pressure 100–170 mmHg, was evaluated. High, intermediate, and low risks were determined using the Framingham Risk Score (FRS), Pooled Cohort Equation (PCE), four versions of Systematic Coronary Risk Evaluation 2 (SCORE2), and Multi-Ethnic Study of Atherosclerosis (MESA) algorithm (0–1000 Agatston Units) Results Concordance for the three levels of risk varied from 19% to 85%. Both sexes might be considered to have low, intermediate, or high risk depending on the algorithm applied, even with the same burden of risk factors. Only SCORE2 (High Risk and Very High Risk versions) identified equal proportions of males and females with high risk. Excluding MESA, the proportion with moderate risk was 25% (SCORE2, Very High Risk Region), 32% (FRS), 39% (PCE), and 45% (SCORE2, Low Risk Region) Conclusion Risk algorithms differ substantially in their estimation of risk, recommendations for statin treatment, and use of ancillary testing, even in identical patients. These results highlight the limitations of currently used risk-based approaches for addressing lipid-specific risk in primary prevention. A simulated population was created to compare risk stratification of men and women as well as smokers and non-smokers across the entire spectrum of age, systolic blood pressure, total cholesterol (TC), and high-density lipoprotein cholesterol (HDL-C) reflecting the full ranges appropriate for application of the Framingham Risk Score (FRS), the Pooled Cohort Equation (PCE), and the region-specific versions of Systematic Coronary Risk Evaluation 2 (SCORE2).