Original Title: Avis: statines, hypolipémiants et diminution du risque cardiovasculaire

Authors' objectives: With a view to improving cardiovascular health, ensuring the optimal use of statins and other lipid-lowering agents, and, ultimately, avoiding unnecessary expenses that do not provide any health benefits, the Ministère de la Santé et des Services sociaux asked the Institut national d’excellence en santé et en services sociaux to produce a clinical relevance report on the use of statins and other lipid-lowering agents in primary prevention, including in people over 75 years of age. At the end of this report, INESSS presents the best practices for the global management of cardiovascular risk factors. Identifying the gaps between these best practices and those currently employed in Quebec primary care in Québec led us to make recommendations for decision-makers and clinicians with the aim of optimizing the use of statins and other lipidlowering agents in cardiovascular risk prevention, including secondary prevention.

Authors' results and conclusions: RESULTS: The recommendations extracted from the 11 selected clinical practice guidelines vary substantially, even though they are often based on the same scientific data. With advances in knowledge of the pathophysiology of atherosclerosis, now known to be a silently progressing, multifactorial disease rather than one that is solely cholesterol-dependent, these new data should be taken into account when identifying patients at risk to ensure a proper evaluation. CONCLUSION: As part of this report, the use of statins and other lipid-lowering agents was examined in the overall context of reducing cardiovascular risk. The regular assessment of the relevance of treatment and the enhancement of therapeutic adherence, including lifestyle changes, emerged as measures for optimizing cardiovascular risk reduction. All the clinical practice guidelines agree that healthy life habits are the cornerstone of this management and, for a large percentage of them, apart from people with existing clinical signs, the prescribing of statin therapy is contingent on the failure to adhere to healthy life habits. In short, the general practitioner needs to be supported throughout the patient’s lifestyle modification process and the decision-making process for the best strategy for reducing his/her cardiovascular risk, this while respecting his/her values and preferences. Fortunately, there are qualified professionals and a good number of winning conditions in Quebec. However, these conditions necessarily require public education campaigns that would use a common language and programs for promoting informed/shared decision-making in the area of cardiovascular disease prevention.

Authors' methods: The scientific, contextual and experiential data on the pathophysiological aspects of atherosclerosis, the clinical and organizational aspects of cardiovascular disease (CVD) prevention, the use of lipid-lowering agents in Quebec, and the coverage policies for lipid lowering agents in Canada and internationally were gathered using various methodological approaches. A narrative review was conducted to document the pathophysiological aspects of and risk factors for atherosclerosis, and three systematic reviews were performed to document the clinical aspects in accordance with INESSS’s standards. One of the systematic reviews focused on best clinical practice recommendations (2010-2015; updated in February 2017), the other two, the effectiveness of healthy life habits in reducing cardiovascular risk, namely, physical activity and the Mediterranean diet. To enrich the safety and efficacy data on statins, which had already been documented in the best practice recommendations, one of the systematic reviews supporting the selected clinical practice guidelines concerning these aspects and considered to be of good methodological quality was analyzed. A second analysis, of a second systematic review, published by Cochrane, was performed to calculate the number needed to treat (NNT) to prevent a first coronary event over a 5-year period according to the risk level and treatment persistence. The safety data were supplemented by searches in product monographs and reports from regulatory agencies. The clinical practices and organizational aspects specific to Quebec were documented during consultations with different stakeholders, including the members of the advisory and follow-up committees, and were validated by means of a targeted search in the literature on management frameworks, policies, government programs, the available resources, and laws and regulations. Lastly, a retrospective cohort study was carried out using the four digital files stored at the Régie de l’assurance maladie du Québec, in order to provide an overview of lipid-lowering agents use in adults covered by the public drug insurance plan from 2010 to 2015.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/statines-hypolipemiants-et-diminution-du-risque-cardiovasculaire.html

Year Published: 2017

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/statines-hypolipemiants-et-diminution-du-risque-cardiovasculaire.html

Requestor: Minister of Health

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)