Lifetime risk: does it help to decide who gets statins and when?

The new risk-based guidelines on blood cholesterol treatment from the American College of Cardiology and the American Heart Association reflect the now widespread international agreement that lipid-lowering treatment decisions should be based primarily on individuals' predicted cardiovascular disease (CVD) risk rather than LDL-cholesterol levels. Most risk-based guidelines recommend using short-term (5-year or 10-year) predicted cardiovascular disease risk to inform treatment decisions; however, some commentators now advocate using predicted lifetime risk because people with low short-term risk but high long-term risk could miss out on effective treatment. This review addresses the question: 'should predicted lifetime as well as short-term cardiovascular disease risk inform who gets statins and when?'

The seminal 2012 Cholesterol Treatment Trialists' individual participant meta-analysis of statin trials convincingly demonstrated that the magnitude of CVD-risk reduction is directly proportional to individuals' pretreatment-predicted short-term CVD risk. Several studies have recently reported lifetime cardiovascular disease risk trajectories and show that the vast majority of adults are at high lifetime cardiovascular disease risk, even when risk factors are optimal. An alternative cardiovascular disease risk prediction approach that forecasts short-term risk over a person's lifetime has also been reported recently.

Predicted short-term cardiovascular disease risk predicts short-term cardiovascular disease treatment benefits of statins and should inform who gets statins and when. Predicted lifetime cardiovascular disease risk classifies almost everyone at high risk and so does not usefully inform who will gain most from statins. A risk trajectory that predicts short-term risk throughout a person's lifetime could address the deficiencies of both short-term and lifetime risk assessments.