Cardiovascular risk estimation and statin adherence: An historical cohort study

BackgroundAdherence to statins for the primary prevention of cardiovascular disease (CVD) is low. There is evidence that some facets of the initiation consultation, or the initiating clinician, are associated with adherence. CVD risk estimation is fundamental to statin initiation and shared decision making (SDM), because the benefits of statins are proportional to CVD risk. Absence of a recorded CVD risk score before statin initiation therefore indicates SDM is unlikely. This study investigates whether, in primary prevention, SDM, using CVD risk score as a proxy measure, is associated with adherence to statins and CVD outcomes. MethodA cohort of statin naive patients aged 40-84 years initiated on statins for primary prevention between 2017 and 2020 was identified and categorised by the presence or absence of a CVD risk score at statin initiation. Statin adherence and persistence was determined from subsequent statin prescriptions. Multivariable modelling, accounting for potential confounders determined the association between a recorded CVD risk score and statin adherence and persistence. A secondary analysis investigated the relationship with subsequent CVD outcomes and death. Results255,730 patients were included with a mean follow up of 4.6 years. 67.7% had a CVD risk score coded. The presence of a CVD risk score increased odds of adherence at the end of year one by 7% and reduced the chances of discontinuation by 8%. The composite outcome of CVD and all-cause mortality was decreased by 21% when a CVD risk score was present. ConclusionWhen a statin is initiated in the presence of a CVD risk score there is a small, but significant improvement in both adherence and persistence which could indicate that the quality of initiation consultations, and a focus on SDM, improves the utility of statins. Additionally, CVD risk scoring is associated with a large decrease in CVD/death which cannot fully be explained by improvements in statin adherence and persistence; an important finding necessitating further investigation. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIWe present a comprehensive assessment of the adherence to and persistence with statins for the primary prevention of CVD which, for the first time, is linked to the presence or absence of CVD risk scoring. C_LIO_LICVD risk scoring is associated with improvements and both adherence and persistence as well as significant reductions in CVD and all-cause mortality. C_LI What are the clinical implications?O_LIThere should be renewed focus on the content of statin initiation consultations ensuring that CVD risk is communicated using a shared decision-making approach. C_LIO_LIFurther consideration should be given to the important discrepancy in CVD and death seen when CVD risk scoring is, and is not, used in practice. C_LI