5 Steps to prevent Heart Disease

Monday, July 4, 2016

Explaining NNT over 5 years

Great work by Dr. Underberg & Kristen Monaco
link to whole article above


Stats on Statins

Robinson: In the 2013 ACC/AHA cholesterol guideline we recommended statins for groups of patients where there was a clear margin of benefit [clinical cardiovascular disease, genetic high LDL-C (>190 mg/dl), or diabetes]. When the margin of benefit may be less clear, such as in primary prevention patients with >7.5% 10-year ASCVD risk, we encouraged shared decision-making by the patient and the clinician.
Studies have shown that patients on average think an NNT (number needed to treat) of 30 would be reasonable for a preventive medication, while for physicians a reasonable NNT(number needed to treat) is 50.
Of course the time horizon matters as well. (NNT over 5 yrs. Is much higher over 20 years) My insert.

Underberg: Statins should be used in those who will benefit most from them, with the least likelihood of side effects and even then, a shared decision process between the healthcare practitioner and the patient will allow for an informed decision process that makes the most sense for every individual.
We still take care of patients one at a time, and this means the use of medications needs to be addressed with personalized approach.
What works for one patient may not always be true for others.
When looking at the totality of evidence statins lower LDL-cholesterol and most importantly they reduce cardiovascular events in patients at risk for cardiovascular disease.
Assessing risk prior to use, and a complete discussion of potential side effects is intrinsic to any pharmacologic intervention in the shared decision making paradigm.

Davidson: The statin trials were only 2-5 years in duration and yet there were major clinical benefits demonstrated.
There are very few therapies that can reverse many years of exposure to a causal risk factor such as elevated LDL-C.
Once a lifetime of benefits can be factored in as well, statins have a much more favorable number needed to treat.

Martin: The NNT will tend to decrease over a longer time horizon.
The typical clinical trial duration of 3-5 years for statin therapy is considerably shorter than the anticipated treatment period of decades for many patients.
Therefore,
the often-quoted NNT values are not reflective of the expected NNT in clinical practice.

Erwin: Statins have clearly positively impacted the trajectory of coronary artery disease in both the primary and secondary prevention arenas.
It is important, however, to treat each case separately and use these medications only in the people who are going to obtain the most benefit from them.

Thompson: The criticism that they help relatively few subjects in 5-year studies is misguided. Who wants to live only 5 years?
Five years studies are only proof of concept studies and the proved concept is that statins prevent cardiovascular events.
I know few cardiologists not on these drugs.
Finally, who can say that stopping statins is such a terrible thing?
The West of Scotland follow up demonstrated that only 5 years of statin treatment provided benefit that extended for 20 years after the study, and coronary regression studies show that much of the regression of atherosclerosis occurs in the first two years of statin treatment. Consequently, estimates of the risk of stopping statins are simply estimates because we have not actually studied that risk.

Good reason to determine lifetime risk with:


Calculators for Lifetime risk 


 

No comments:

Post a Comment