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Approximately 20 million people in the U.S. have atherosclerotic cardiovascular disease (ASCVD). The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend statin therapy for ASCVD patients to lower cholesterol and reduce risk of heart attack or stroke.

In 2013, the ACC/AHA updated their guidelines to recommend high-intensity statin use for ASCVD patients age 75 and younger.

A team from Mayo Clinic looked at trends in statin use, adherence, cost and clinical outcomes in the periods before and after this update to the guidelines. Their findings were published in JAMA Network Open.



The team analyzed data from 284,954 patients who had their first ASCVD event between 2007 and 2016.

Trends were assessed in the overall population as well as in three subgroups of patients, including those with (1) cardiovascular heart disease (CHD), (2) ischemic stroke or transient ischemic attack (TIA) and (3) peripheral artery disease (PAD).

Between 2007 and 2016, in the overall population there was a modest increase in statin use (from 50% to 59.9%) and adherence (from 58.7% to 70.5%). The use of high-intensity statins approximately doubled over this time frame (from 25% to 49.2%). 

The 1-year risk of major adverse cardiac events (MACE) decreased from 8.9% to 6.5%, translating to 525,600 fewer MACE per year, associated with an increase in the use and intensity of statins. 

When digging into subgroup analyses, the findings revealed major treatment gaps for cardiovascular patients:

  • Under-treatment for PAD, ischemic stroke and TIA patients: Use of statins and high-intensity statins as well as adherence to statins were lower in patients with ischemic stroke, TIA and PAD compared to those with CHD. Notably, only 1 in 3 patients with PAD received a statin and only 1 in 15 received a high-intensity statin.
  • Race and sex disparities: Women, Black and Hispanic individuals were less likely to receive and adhere to statin therapy. Women were approximately 20% less likely to receive statins or high-intensity statins than men and 14% less likely to adhere to medications. Black and Hispanic patients were 10% less likely to receive statins and 40% less likely to adhere to medications.
  • Barriers to adherence: Though use of generic statins more than doubled and both total costs per month (from $88.90 to $10.80) and median out-of-pocket costs (from $20 to $2) decreased, adherence only modestly increased. Nearly 30% of patients did not adhere to statins, suggesting there may have been barriers to adherence unrelated to costs. 

Improving clinical practice

Results have spotlighted significant opportunities in cardiac risk prevention. The Mayo Clinic researchers see lots of opportunity to make progress in both prescribing and adherence.

“The risk of adverse outcomes has decreased overall. However, it is apparent that major treatment gaps exist in our country,” says Peter Noseworthy MD, cardiologist and senior author. “Although the guidelines recommend statins for stroke, TIA and PAD, there appears to be an unwillingness to consider these and cardiovascular disease equally treatable with statins.”

“Gaps in both prescribing and continuation of statins for at least a year after discharge among women, and Black, Hispanic and Asian people mean that they will be more likely to experience avoidable adverse outcomes,” says Xiaoxi Yao, PhD study leader. “If your physician prescribes statins, please adhere to the drugs,” she says. “Some people say, ‘I took the drug for a while, but nothing happened, so I stopped.’ A statin is a drug to prevent cardiac events, stroke and death. So ‘nothing happened’ is actually the goal.”