Cardiovascular risk estimation and statin adherenceAn historical cohort study

Background Adherence 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.

A cohort of statin naïve 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.

255,730 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.

When 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. What is new? We 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. CVD risk scoring is associated with improvements and both adherence and persistence as well as significant reductions in CVD and all-cause mortality. What are the clinical implications? There should be renewed focus on the content of statin initiation consultations ensuring that CVD risk is communicated using a shared decision-making approach. Further consideration should be given to the important discrepancy in CVD and death seen when CVD risk scoring is, and is not, used in practice. Competing Interest Statement The authors have declared no competing interest. Funding Statement This research was unfunded Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This research was approved by CPRD, approved protocol number 23_003321 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Primary data is not available through the authors due to data sharing restrictions but is available to researchers through CPRD (subject to approvals). Code lists used in data extraction and processing are available on request from the corresponding author.