A critical re-evaluation of the criteria for prescribing statin medications is underway, driven by the emergence of a more advanced risk assessment tool for cardiovascular disease. The new PREVENT model, which incorporates a broader spectrum of patient data, has prompted experts to reconsider the risk thresholds that determine statin eligibility. This development is crucial as medical bodies work to update guidelines, aiming to strike a delicate balance between maximizing the preventative benefits of statins and mitigating potential side effects, such as an elevated risk of developing type 2 diabetes. The discourse centers on ensuring that those most likely to benefit receive appropriate treatment, while avoiding unnecessary medication for others, ultimately striving for improved public health outcomes in the fight against heart attacks and strokes.

The estimation of atherosclerotic cardiovascular disease risk has seen significant evolution with the introduction of the PREVENT model in November 2023. This calculator garnered considerable acclaim for its comprehensive approach, integrating data from a more contemporary and diverse segment of the American population compared to its predecessors. Initially, there were concerns that this advanced model might lead to a substantial reduction—potentially 40%—in the number of U.S. adults qualifying for statin therapy. However, subsequent analysis has indicated that by adjusting the treatment thresholds, approximately the same number of individuals could remain eligible for these vital cholesterol-lowering medications.

A recent research letter published in JAMA Cardiology shed light on how various thresholds would impact statin eligibility when applied to the PREVENT model. The PREVENT model uniquely accounts for additional factors such as chronic kidney disease, diabetes, obesity, and other metabolic conditions, providing a more holistic risk assessment. The older Pooled Cohort Equations model, established in 2013, recommended statins for individuals with a 10-year cardiovascular event risk of 7.5%. When this same 7.5% threshold was applied to the PREVENT data, a significantly smaller population was deemed eligible. The new analysis explored lowering this threshold to 3%, 4%, or 5% over a decade. Researchers found that a 3% risk threshold over 10 years would result in similar numbers of eligible patients as the previous guidelines, reflecting the more precise risk stratification offered by the PREVENT model.

While statins are highly effective in preventing cardiovascular events, their use is not without considerations. Some patients experience muscle discomfort, and a more significant concern is the potential for an increased risk of developing type 2 diabetes. Clinical trials have shown that about 3% of statin users might develop diabetes over a ten-year period, particularly those with pre-diabetic blood glucose levels. This raises a crucial question for clinicians: does the cardiovascular benefit outweigh the potential for developing diabetes, especially for patients already at risk? Despite these considerations, experts like Gregg Fonarow, a cardiologist at UCLA, argue that the benefits of statins extend to even lower risk thresholds, potentially preventing a greater number of cardiovascular events across the population.

As the American Heart Association and the American College of Cardiology prepare to release updated guidelines in the spring, the goal is not merely to maintain existing patient numbers but to accurately identify those who will genuinely benefit from statin therapy. The shift to more contemporary data in the PREVENT equations leads to lower risk estimates compared to older tools, necessitating a recalibration of treatment thresholds. The ultimate aim is to ensure that healthcare providers and patients can engage in informed discussions, weighing the scientific evidence, individual risk factors, and personal preferences to arrive at the most appropriate treatment decisions for preventing cardiovascular disease.