Statins for Prevention of Cardiovascular Disease in Adults

Importance: Cardiovascular disease (CVD), the leading cause of mortality and morbidity in the United States, may be potentially preventable with statin therapy. Objective: To systematically review benefits and harms of statins for prevention of CVD to inform the US Preventive Services Task Force. Data Sources: Ovid MEDLINE (from 1946), Cochrane Central Register of Controlled Trials (from 1991), and Cochrane Database of Systematic Reviews (from 2005) to June 2016. Study Selection: Randomized clinical trials of statins vs placebo, fixed-dose vs titrated statins, and higher- vs lower-intensity statins in adults without prior cardiovascular events. Data Extraction and Synthesis: One investigator abstracted data, a second checked data for accuracy, and 2 investigators independently assessed study quality using predefined criteria. Data were pooled using random-effects meta-analysis. Main Outcomes and Measures: All-cause mortality, CVD-related morbidity or mortality, and harms. Results: Nineteen trials (n = 71 344 participants range, 95-17 802; mean age, 51-66 years) compared statins vs placebo or no statin. Statin therapy was associated with decreased risk of all-cause mortality (risk ratio RR, 0.86 95% CI, 0.80 to 0.93; I2 = 0%; absolute risk difference ARD, -0.40% 95% CI, -0.64% to -0.17%), cardiovascular mortality (RR, 0.69 95% CI, 0.54 to 0.88; I2 = 54%; ARD, -0.43% 95% CI, -0.75% to -0.11%), stroke (RR, 0.71 95% CI, 0.62 to 0.82; I2 = 0; ARD, -0.38% 95% CI, -0.53% to -0.23%), myocardial infarction (RR, 0.64 95% CI, 0.57 to 0.71; I2 = 0%; ARD, -0.81% 95% CI, -1.19 to -0.43%), and composite cardiovascular outcomes (RR, 0.70 95% CI, 0.63 to 0.78; I2 = 36%; ARD, -1.39% 95% CI, -1.79 to -0.99%). Relative benefits appeared consistent in demographic and clinical subgroups, including populations without marked hyperlipidemia (total cholesterol level <200 mg/dL); absolute benefits were higher in subgroups at higher baseline risk. Statins were not associated with increased risk of serious adverse events (RR, 0.99 95% CI, 0.94 to 1.04), myalgias (RR, 0.96 95% CI, 0.79 to 1.16), or liver-related harms (RR, 1.10 95% CI, 0.90 to 1.35). In pooled analysis, statins were not associated with increased risk of diabetes (RR, 1.05 95% CI, 0.91 to 1.20), although statistical heterogeneity was present (I2 = 52%), and 1 trial found high-intensity statins associated with increased risk (RR, 1.25 95% CI, 1.05 to 1.49). No trial directly compared titrated vs fixed-dose statins, and there were no clear differences based on statin intensity. Conclusions and Relevance: In adults at increased CVD risk but without prior CVD events, statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and CVD events, with greater absolute benefits in patients at greater baseline risk.