Statin Use Has Plateaued in US Primary Prevention Patients

The number of patients taking statins for primary prevention has increased in the United States over the past two decades, but the percentage of eligible patients on treatment has appeared to plateau in recent years, according to the results of a new study.

In an analysis from the National Health and Nutrition Examination Survey (NHANES), the proportion of guideline-eligible patients who reported taking a statin increased from 11.6% in 1999-2000 to 33.6% in 2013-2014, at which point there was no further change in statin use.

“We had gone into the study thinking there would be an increase in statin use over time, at least with the change in the 2013 guidelines, especially since they expanded eligibility for a lot more adults,” lead investigator Casey J. Kim, MD (Beth Israel Deaconess Medical Center, Boston, MA), told TCTMD. “With a lot more of these adults newly eligible, then you would expect to see a proportionate increase [in statin use], which didn’t really play out at all. Not only was there a plateau in total statin use, but for adults who were newly recommended statins, we didn’t really see much of a change there either.”

In the 2013 cholesterol guidelines from the American College of Cardiology/American Heart Association (ACC/AHA), statin therapy was recommended for adults with LDL-cholesterol levels 190 mg/dL or greater, those with an elevated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) and LDL levels ranging from 70 to 190 mg/dL, and patients with diabetes. These guidelines have since been updated, but researchers used the older ACC/AHA recommendations, as well as the 2002 Adult Treatment Panel (ATP) III guidelines, to assess guideline-eligibility given that their analysis spanned from 1999 to 2018.

Published December 4, 2023, in the Annals of Internal Medicine, the study included 21,961 adults enrolled in NHANES, representing approximately 173.9 million people. Of these, 35.6% had an indication for statin therapy for primary prevention. Overall, the percentage of guideline-eligible patients taking statins increased 11.6% in 1999-2000 to 32.4% in 2017-2018, but there was no change in uptake from 2013-2014 onwards.

For adults newly recommended statins following the introduction of the 2013 ACC/AHA guidelines, there was also no change in statin use from 2013-2014 to 2017-2018.

Investigators also looked at use of statins over time by indication. For the overall study period, there was no change in statin use for adults with an indication based on very high LDL levels (≥ 190 mg/dL). From 1999-2000 to 2013-2014, there was an absolute 31.1% increase in the percentage of diabetic patients taking statins and an absolute 19.3% increase in statin use among those with a 10-year ASCVD risk exceeding 5%, but neither group had any significant changes in statin use beyond 2013-2014.

Even among adults with a very high 10-year risk of ASCVD (> 20%), there was an absolute 23.1% increase in statin use from 1999-2000 to 2013-2014, but uptake plateaued at this point, too. For those with 10-year ASCVD risks of 5.0% to 7.5% and 7.5% to 19.9%, there were no changes in statin use during the entire study period.

These findings, said Kim, were surprising, particularly the plateau in the highest-risk patients. “You would hopefully expect most of those people to be on statins,” she said. 

As to why the number of primary-prevention patients on statins remains stubbornly low, Kim said there are likely several reasons. Predictors of statin use in their study—findings that didn’t make it into their brief research report—included insurance and healthcare access. For many patients, “there are barriers every step of the way,” she said. “How do we get people in just to see a healthcare provider who will prescribe a statin?”

Additionally, there are physician-related factors that might influence statin use. Kim said that calculating the patient’s 10-year risk of ASCVD is a complex, multistep process, something that might be overlooked during a visit with a busy primary-care physician. Tools embedded in the electronic health record to calculate ASCVD risk are one possibility that might help raise awareness that the patient is eligible for a statin, she said. On a population level, campaigns around the importance of lipid control would also be beneficial, she said.

“It might not be unreasonable to think that setting a certain target might have some success,” said Kim. “If you focus on patients with an atherosclerotic cardiovascular risk score greater than 20%, the goal could be to get 50% of those adults on a statin by X amount of time. I think there's a lot of work that could be done if you were to focus on these very-high-risk populations.”