A Contrarian View

Contact: fayw@missouri.edu 3-Hydroxy-3-methyl-glutarylCoA reductase inhibitors, or statins, are a mainstay in the treatment of patients with established coronary artery disease (CAD) because of their proven effi cacy in reducing cardiovascular death, myocardial infarction, and coronary revascularization procedures in this patient population. Statin therapy has also proven successful in the primary prevention of CAD. However, the absolute reduction in cardiovascular events is lower in primary prevention than in secondary prevention trials, and many of the primary prevention trials enrolled a significant number of patients with established cardiovascular disease and/or other high-risk features, such as diabetes mellitus. For these reasons we do not recommend widespread treatment of the general adult population with a statin. Rather, we advocate a strategy which involves collection of standard clinical data and the use of validated risk-prediction tools to stratify patient risk and limit initiation of a statin to those who are more likely to benefit from such therapy.