Response

Dr Dufour is entirely correct. If we follow only the Adult Treatment Panel III guidelines, 42.3% of adults between 35 and 70 years of age are candidates for statin therapy. If we add C-reactive protein testing, this increases to 52.6%; if we add additional low-density lipoprotein (LDL) triggers (LDL > 3.5 mmol/L), this jumps to 61.7%.¹ The Canadian guidelines incorporate the latter 2 strategies. Currently, less than 50% of Adult Treatment Panel III–eligible patients are taking statins. As two-thirds of the benefit in cardiovascular events is seen with the initial statin dose, and as there is no good evidence for C-reactive protein use and LDL targets, compliance might be best served by evaluating risk and treating those with high scores with a mid-dose generic statin. This is almost sure to improve compliance, and we are much more likely to improve outcomes for high-risk patients in primary prevention. For patients who are happy to obsess about LDL levels, we always have guidelines to fall back on.

The calculator is meant as a decision aid for both guideline and “fire and forget” approaches. A recent revision includes numbers needed to treat, which might be useful for patient decisions.

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