Statin As Primary Prevention in CVD

Statins for the primary prevention of cardiovascular disease
(Review)
Taylor F, Huffman MD, Macedo AF, Moore THM, Burke M, Davey Smith G, Ward K,
Ebrahim S
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 1
http://www.thecochranelibrary.com
Statins for the primary prevention of cardiovascular disease (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Statins for the primary prevention of cardiovascular disease (Review) i

[Intervention Review]
Fiona Taylor1 , Mark D Huffman2 , Ana Filipa Macedo3 , Theresa HM Moore4 , Margaret Burke5 , George Davey Smith6 , Kirsten Ward
7 , Shah Ebrahim1
1
Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
2 Departments of Preventive Medicine and Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago,
USA. 3 Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal. 4 Academic Unit of Psychiatry, School of Social and
Community Medicine, University of Bristol, Bristol, UK. 5 Department of Social Medicine, University of Bristol, Bristol, UK. 6 School
of Social and Community Medicine, University of Bristol, Bristol, UK. 7 Department of Twin Research & Genetic Epidemiology,
King’s College London, London, UK
Contact address: Fiona Taylor, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical
Medicine, Keppel Street, London, WC1E 7HT, UK. [email protected].
Editorial group: Cochrane Heart Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 1, 2013.
Review content assessed as up-to-date: 1 January 2012.
Citation: Taylor F, Huffman MD, Macedo AF, Moore THM, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the
primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD004816. DOI:
10.1002/14651858.CD004816.pub5.
ABSTRACT
Background
Reducing high blood cholesterol, a risk factor for cardiovascular disease (CVD) events in people with and without a past history of CVD
is an important goal of pharmacotherapy. Statins are the first-choice agents. Previous reviews of the effects of statins have highlighted
their benefits in people with CVD. The case for primary prevention was uncertain when the last version of this review was published
(2011) and in light of new data an update of this review is required.
Objectives
To assess the effects, both harms and benefits, of statins in people with no history of CVD.
Search methods
To avoid duplication of effort, we checked reference lists of previous systematic reviews. The searches conducted in 2007 were updated
in January 2012. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2022, Issue
4), MEDLINE OVID (1950 to December Week 4 2011) and EMBASE OVID (1980 to 2012 Week 1).There were no language
restrictions.
Selection criteria
We included randomised controlled trials of statins versus placebo or usual care control with minimum treatment duration of one year
and follow-up of six months, in adults with no restrictions on total, low density lipoprotein (LDL) or high density lipoprotein (HDL)
cholesterol levels, and where 10% or less had a history of CVD.
Statins for the primary prevention of cardiovascular disease (Review) 1
Data collection and analysis
Two review authors independently selected studies for inclusion and extracted data. Outcomes included all-cause mortality, fatal and
non-fatal CHD, CVD and stroke events, combined endpoints (fatal and non-fatal CHD, CVD and stroke events), revascularisation,
change in total and LDL cholesterol concentrations, adverse events, quality of life and costs. Odds ratios (OR) and risk ratios (RR)
were calculated for dichotomous data, and for continuous data, pooled mean differences (MD) (with 95% confidence intervals (CI))
were calculated. We contacted trial authors to obtain missing data.
Main results
The latest search found four new trials and updated follow-up data on three trials included in the original review. Eighteen randomised
control trials (19 trial arms; 56,934 participants) were included. Fourteen trials recruited patients with specific conditions (raised
lipids, diabetes, hypertension, microalbuminuria). All-cause mortality was reduced by statins (OR 0.86, 95% CI 0.79 to 0.94); as was
combined fatal and non-fatal CVD RR 0.75 (95% CI 0.70 to 0.81), combined fatal and non-fatal CHD events RR 0.73 (95% CI
0.67 to 0.80) and combined fatal and non-fatal stroke (RR 0.78, 95% CI 0.68 to 0.89). Reduction of revascularisation rates (RR
0.62, 95% CI 0.54 to 0.72) was also seen. Total cholesterol and LDL cholesterol were reduced in all trials but there was evidence of
heterogeneity of effects. There was no evidence of any serious harm caused by statin prescription. Evidence available to date showed
that primary prevention with statins is likely to be cost-effective and may improve patient quality of life. Recent findings from the
Cholesterol Treatment Trialists study using individual patient data meta-analysis indicate that these benefits are similar in people at
lower (< 1% per year) risk of a major cardiovascular event.
Authors’ conclusions
Reductions in all-cause mortality, major vascular events and revascularisations were found with no excess of adverse events among
people without evidence of CVD treated with statins.
PLAIN LANGUAGE SUMMARY

Cardiovascular disease (CVD), which comprises heart attacks (myocardial infarction), angina and strokes, is ranked as the number one
cause of mortality and is a major cause of morbidity world wide. High blood cholesterol is linked to CVD events and is an important risk
factor. Reducing high blood cholesterol, is thus an important way to reduce the chances of suffering a CVD event. Statins - cholesterol
lowering drugs - (e.g. simvastatin, pravastatin, atorvastatin) are the first-choice treatments. Since the early statin randomised controlled
trials were reported in the 1990s, several reviews of the effects of statins have been published highlighting their benefits particularly in
people with a past history of CVD. Benefits include a reduction in CVD events. Statins have also been shown to reduce the risk of
a first event in otherwise healthy individuals at high risk of CVD (primary prevention) but information on possible hazards has not
been reported fully. The aim of this updated systematic review is to assess the effects, both in terms of benefits and harms of statins,
for the primary prevention of CVD. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and
EMBASE until 2011. We found 18 randomised controlled trials with 19 trial arms (56,934 patients) dating from 1994 to 2008. All
were randomised control trials comparing statins with usual care or placebo. The mean age of the participants was 57 years (range
28 - 97 years), 60.3% were men, and of the eight trials that reported on ethnicity, 85.9 % were Caucasian. Duration of treatment
was a minimum one year and with follow-up of a minimum of six months. All-cause mortality and fatal and non-fatal CVD events
were reduced with the use of statins as was the need for revascularisation (the restoration of an adequate blood supply to the heart)
by means of surgery (coronary artery bypass graft ) or by angioplasty (PTCA). Of 1000 people treated with a statin for five years, 18
would avoid a major CVD event which compares well with other treatments used for preventing cardiovascular disease. Taking statins
did not increase the risk of serious adverse effects such as cancer. Statins are likely to be cost-effective in primary prevention.

BACKGROUND
Since the early statin trials were reported in the early 1990s, sev-
eral reviews of the effects of statins have been published highlight-
ing the benefits of their use (Baigent 2005; Bartlett 2003; Blauw
Burden of cardiovascular disease 1997; Briel 2004; Cheung 2004; Ebrahim 1999; Katerndahl 1999;
LaRosa 1994; LaRosa 1999; Law 2003; Pignone 2000; Silva 2006;
Cardiovascular disease (CVD) encompasses a wide range of disease
Thavendiranathan2006; Ward 2007; Wilt 2004). The Cholesterol
including coronary heart disease (e.g. heart attack, angina), cere-
Treatment Trialists (CTT) Collaboration has used individual pa-
brovascular disease (ischaemic and haemorrhagic stroke), raised
tient data in their meta-analyses to show consistency of treatment
blood pressure, hypertension, rheumatic heart disease and heart
benefits across a wide range of patient subgroups (Baigent 2005).
failure. In the context of this review the major causes of CVD
More recent evidence from the CCT Collaboration has demon-
are unhealthy diets, tobacco use and physical inactivity (WHO
strated that statins are beneficial in reducing the risk of CVD events
2008).
in people without prior evidence of CVD (CTT Collaboration
CVD is ranked as the number one cause of mortality and is a major
2010). A 2012 CTT Collaboration report further demonstrated
cause of morbidity world wide accounting for 17 million deaths,
a consistent 20% relative risk reduction in major vascular events
30% of total deaths. Of these, 7.6 million are due to heart attacks
with statins per 1mmol/L reduction in LDL cholesterol, regardless
and 5.7 million due to stroke (WHO 2008). Over 80% of CVD
of baseline risk (CTT Collaboration 2012a). Men and women,
deaths occur in low- and middle-income countries (WHO 2008).
old and young, and people with and without CVD all appear to
In developing countries, it causes twice a many deaths as HIV,
benefit. These findings confirm the efficacy of statins for primary
malaria and tuberculosis combined (Gaziano 2007). It has been
prevention, resolving concerns about possible serious adverse ef-
estimated that between 1990 and 2020, the increase in ischaemic
fects and potential sources of bias in the randomised trials high-
heart disease alone will increase by 29% in men and 48% in women
lighted in an earlier version of this Cochrane review.
in developed countries and by 120% in women and 127% in men
in developing countries (Yusuf 2001). CVD imposes high social
costs, including impaired quality of life and reduced economic
activity and accounts for a large share of health service resources Adverse effects of statins
(Gaziano 2007). There has been some concern, primarily from observational stud-
CVD is multi-factorial in its causation and lifestyle changes are ies, that low levels of blood cholesterol increase the risk of mortal-
the basis of any treatment strategy, with patients often requiring ity from causes other than coronary heart disease (CHD), includ-
behavioural counselling. Those unable to achieve or maintain ade- ing cancer, respiratory disease, liver disease and accidental/violent
quate risk reduction through lifestyle changes alone or those at high death. Several studies have now demonstrated that this is mostly,
risk may benefit from pharmacotherapy. High blood cholesterol or entirely, due to the fact that people with low cholesterol lev-
(hypercholesterolaemia) is a risk factor for both fatal and non-fatal els include a disproportionate number whose cholesterol has been
CVD events in people with and without a past CVD (Prospective reduced by illness - early cancer, respiratory disease, gastrointesti-
Studies Collaboration 2007), and lowering cholesterol, in par- nal disease and alcoholism, among others (Iribarren 1997; Jacobs
ticular low density lipoprotein (LDL) cholesterol, is an impor- 1997). Thus it appears to be the pre-existing disease which causes
tant target for pharmacotherapy. Statins are the first-choice agents both the low cholesterol and raised mortality (Davey Smith 1992).
for LDL cholesterol reduction. Since the relation between blood The potential adverse effects of statins among people at low risk
cholesterol and cardiovascular risk is continuous (Chen 1991), of CVD were poorly reported and unclear in earlier trials (Jackson
there is no definite threshold to initiate treatment. If a threshold 2001), but among those with and without pre-existing CVD the
for ’high’ cholesterol is set at over 3.8 mmol/L, (146.9 mg/dL) this evidence now suggests that any possible hazards are far outweighed
would contribute 4.4 million deaths worldwide and 40.4 million by the benefits of treatment. Two reviews of 18 and 35 trials respec-
disability-adjusted life years (DALYs) (Ezzati 2002). Furthermore, tively found that there were similar rates of serious adverse events
the average level of blood cholesterol within a population is an with statins as compared to placebo (Kashani 2006; Silva 2006).
important determinant of the CVD risk of the population. Differ- Individual patient data meta-analyses conducted by the CTT Col-
ences in average levels of blood cholesterol between populations laboration have demonstrated unequivocally that there is no excess
are largely determined by differences in diet, and countries with risk of cancers (CTT Collaboration 2012b), confirming the find-
higher dietary saturated fat intake and a lower ratio of polyunsat- ings of an earlier review and has reported reductions in all-cause
urated to saturated fatty acids have higher than average cholesterol mortality and no excess of non-vascular mortality (Dale 2006).
levels (Davey Smith 1992). Rhabdomyolysis - break down of muscles - which can be serious
if not detected and treated early (Beers 2003) may be caused by
statins, but this is very rare. In a systematic review of randomised
trials of statins with about 35,000 people and 158,000 person years
Trial evidence for use of statins of observation in both treated and placebo groups, rhabdomyoly-

sis was diagnosed in eight treated and five placebo patients, none Ebrahim 1999; NICE 2006; Thavendiranathan2006; Vrecer,
with serious illness or death (Law 2003). 2003; Ward 2007). This is largely due to the differing inclusion
An increased risk of incident type 2 diabetes associated with statin criteria of the reviews and differences in reporting of outcomes.
therapy compared with usual care or placebo has been reported The most recent systematic review, using individual participant
(Mills 2011; Sattar 2010) and with high dose versus usual dose data from the majority of statin trials, provides strong evidence that
statins (Preiss 2011). The mechanism by which statins may in- benefits from statins outweigh any possible serious adverse effects,
crease diabetes risk is not known. Haemorrhagic stroke appears to even at very low levels of CVD event rates (CTT Collaboration
be increased by statin treatment, although estimates are imprecise, 2012a). These new findings counter earlier opinion that the evi-
with an annual risk of 0.5 per 1000 patients treated for five years dence is insufficient to support use of statins in primary prevention
which is small compared with the benefits seen on the overall risk for women or in older men (Abramson 2007). Previous reviews,
of stroke (CTT Collaboration 2012a). Two recent meta-analyses in addition, have not reported other relevant outcomes such as
of large-scale placebo or standard care controlled trials observed a costs, patient quality of life nor have they focused their attention
9% increased risk for incident diabetes associated with statin ther- on detailed reporting of adverse side effects.
apy, with little heterogeneity between studies. In Mills 2011(Mills The aim of this systematic review is to update and include further
2011), 17 randomised controlled trials (RCTs) reported an in- trials that have been published since the last search (to 2007) and
creased risk of the development of diabetes. contextualise our findings with those recently published by the
Other possible adverse events derived from small trials have been CTT Collaboration.
investigated. In a recent RCT of 1016 adults, statin treatment for
six months was associated with increased self-reporting of reduced
energy and fatigue on exertion (Golomb 2012). An earlier RCT of
621 adults found that statins did not adversely affect self-reported
OBJECTIVES
quality of life, mood, hostility, psychological well being or anger
expression (Wardle 1996). Small decrements in scores on tests of To update this review to assess the effects, both harms and benefits,
psychomotor speed and attention were found by Muldoon et al in of statins in people with no history of CVD events.
an RCT of 209 adults, but Muldoon concluded that more research
is needed to fully evaluate this (Muldoon 2000). In addition, a sys-
tematic review of five statin trials (N = 30,817) found no evidence METHODS
that statins increased the risk of death from non-illness mortality
(accidents, violence or suicide) (Muldoon 2001).
Criteria for considering studies for this review

Guidelines for use of statins
The evidence on the beneficial effects of statins has led expert Types of studies
committees to promote their use on a global scale particularly in Randomised controlled trials (RCTs) comparing treatment with
the developed world. (Genest 2009; Manuel 2006; NICE 2006; statins for at least 12 months with placebo or usual care. Length
Reiner 2011) Statin prescribing and expenditure have risen rapidly of follow-up of outcomes had to be at least six months.
as a result. For example, the European statin prescription average
(weighted by population of each country) increased from 11.12
defined daily doses/1000 in 1997 to 41.80/1000 in 2002, an aver- Types of participants
age 31% increase a year (Walley 2004). The expenditure on statin Men and women (aged 18 or more) with no restrictions on total,
drugs in England was over £20 million in 1993, over £113 million low or high density lipoprotein cholesterol levels. We limited our
in 1997 (Ebrahim 1998) and has risen to more than £500 million inclusion of study population to have less than or equal to 10% of
in 2006 (NICE 2006). a previous history of CVD (this would include previous angina,
myocardial infarction and/or stroke). Trials in which statins were
used to treat or control chronic conditions (e.g. Alzheimer’s dis-
ease, rheumatoid arthritis, renal disease, macular degeneration,
Why it is important to do this review
aortic stenosis) were excluded.
A major limitation of the evidence summaries to date is combining
trials of statins in secondary and primary prevention of CVD with-
out reporting benefits and adverse effects separately. A number of Types of interventions
systematic reviews have focused on statins in primary prevention, Statins (HMG CoA reductase inhibitors) versus placebo or usual
but they differ in their interpretation of the evidence (Brugts 2009; care.

Concommitant interventions as set out in the recommendations in the Cochrane Handbook for
Drug treatments and other interventions were accepted provided Systematic Reviews of Interventions 5.0.2 (Higgins 2011).
they were given to both arms of the intervention groups. Adjuvant
treatments with one additional drug where a patient developed Assessment of risk of bias
excessively high lipids during the trial were accepted.
We used criteria described in the Cochrane Handbook of System-
atic Reviews 5.0.2 (Higgins 2011) to describe the quality of trials
Types of outcome measures we found. Two review authors independently assessed risk of bias
of selected studies (FT and KW for the original review, FT and
The following outcomes were collected:
AM for the update). Any differences of opinion were resolved by
• death from all causes;
discussion and consensus and finally by discussion with a third
• fatal and non-fatal CHD, CVD and stroke events;
author (SE). To assess any risk of bias we focused on the following
• combined endpoint (fatal and non-fatal CHD, CHD and
dimensions as recommended in the Cochrane Handbook for Sys-
stroke events);
tematic Reviews of Interventions.
• change in blood total and low density lipoprotein (LDL)
1. Adequate sequence generation (such as computer-generated
cholesterol concentration;
random numbers and random number tables, whilst inadequate
• revascularisation;
approaches included the use of alternation, case record numbers,
• adverse events;
birth dates or days of the week).
• quality of life;
2. Adequate measures to conceal allocation. Concealment was
• costs.
deemed adequate where randomisation was centralised or
pharmacy-controlled, or where the following were used: serially
numbered containers, on-site computer-based systems where
Search methods for identification of studies assignment is unreadable until after allocation, other methods
As previous comprehensive reviews (Bartlett 2005; Ebrahim 1999; with robust methods to prevent foreknowledge of the allocation
Ward 2007) have been undertaken, we built on this work. The sequence to clinicians and patients
searches conducted in 2007 (Appendix 1) were updated on 10th 3. Blinding was deemed adequate if blinding was applied
January 2012 (Appendix 2). We searched the Cochrane Central (whether the participant, care provider or outcome assessors)
Register of Controlled Trials (CENTRAL) on The Cochrane Li- 4. Completeness of outcome data was deemed adequate if
brary (2011, Issue 4), MEDLINE OVID (1950 to December intention-to-treat analysis was performed for each outcome and
Week 4 2011) and EMBASE OVID (1980 to 2012 Week 1). The not what patient numbers the analysis was confined to.
standard RCT filters used for MEDLINE and EMBASE (Lefebvre 5. Free of selective reporting was deemed adequate if all stated
1996) in 2007 were updated in 2012. The Cochrane sensitiv- outcomes were reported on and presented. We highlighted any
ity- and precision-maximising RCT filter has been applied to the selective outcome reporting.
MEDLINE search (Lefebvre 2011) and the BMJ 2011 has been A ’Risk of bias’ graph for each trial was made available to assess
applied to the EMBASE search. No language restrictions were ap- quality.
plied to either searching or trial inclusion. Reference lists of iden-
tified review articles and of all included RCTs were searched to Data extraction
find other potentially eligible studies.
We designed a data extraction form and included data on our
outcomes measures in addition to:
• study ID;
Data collection and analysis • quality;
• population characteristics terms of CVD risk;
• intervention dosage and duration.
Trial selection
To assess baseline risk of CVD the following median/mean values
Two review authors independently read the results from searches
were also extracted:
on electronic databases to identify those articles relevant to this
• age;
systematic review based on title or title and abstract (FT and KW
• gender ratio;
for the original review, FT and AM for the update). Full articles
• proportion of current smokers;
were retrieved for further assessment. The articles were read in-
• total cholesterol and LDL cholesterol.
dependently by two review authors (FT and KW for the original
review, FT and AM for the update) and a form was designed to Data were independently extracted by two review authors (FT,
describe the characteristics of studies to be included or excluded KW). Any differences of opinion were resolved by discussion and

consensus and finally by discussion with a third review author Analyses for potential effect modifiers was initially considered but
(SE). abandoned due to lack of adequate reporting. We planned to in-
clude:
• gender;
Contacting trialists • extent of hyperlipidaemia;
For unpublished studies or where data were incomplete in pub- • age greater than and less than 65 years.
lished papers, we contacted trial authors to obtain further details.
Sensitivity analysis
Data analysis Sensitivity analysis was used to explore the influence of the fol-
Risk ratios (RR), odds ratio (OR) and 95% confidence intervals lowing on effect size:
(CI) were calculated for dichotomous data. Quantitative analyses • repeating analysis taking account of study quality;
of outcomes was based on ’intention-to-treat’ (ITT). For continu- • repeating analysis excluding any large studies to see how
ous data (such as change in blood total cholesterol), we calculated they influence the results;
pooled mean differences (MD) (with 95% CI). • post-hoc analysis (requested by a peer-reviewer) excluding
We did not add the number of fatal and non-fatal clinical events those trials with any participants with clinical evidence of CVD.
together from any of the studies that we included in this review
as it was not possible to ascertain whether an individual who had
a non-fatal clinical event followed by a fatal clinical event was
counted as a clinical event under both categories. As a result, we RESULTS
have only included the composite of fatal and non-fatal clinical
events if this was reported in the papers. For example, number
of stroke events: 10 trials reported this as a composite outcome,
Description of studies
but three reported on fatal and five on non-fatal stroke events. We
did not add the fatal and non-fatal strokes together to ascertain a See: Characteristics of included studies; Characteristics of excluded
composite number. studies; Characteristics of studies awaiting classification.
For the original review 4227 references were identified after re-
moval of duplicates. From reading titles and abstracts 4128 were
Heterogeneity eliminated as being not relevant to the review. Full papers were ob-
Because trials found may not have been carried out according to a tained for 99 references. From these 99 papers, 72 papers report-
common protocol there will usually be variations in patient groups, ing on 48 studies were excluded (see Characteristics of excluded
clinical settings, concomitant care etc. We, therefore, assessed het- studies). A total of 27 papers reporting on 14 trials were included
erogeneity between trial results. Trial data were considered to be (see Characteristics of included studies).
heterogeneous where the I2 statistic was > 50%. For analysis, we For this update, 6442 references were identified after removal of
used the fixed-effect method unless data were heterogenous in duplicates and off these, 131 full papers were retrieved. From these,
which case we used the random-effects model. Where significant 92 papers were relevant; 35 papers related to seven studies included
heterogeneity was present, we attempted to explain the differences in the original review and 57 papers to five new trials. For one
based on the patient clinical characteristics and interventions of of these (a conference abstract), we were unable to obtain further
the included studies. data (Babes 2010). This study is listed the Table: Characteristics of
studies awaiting classification. We excluded 39 papers: 37 related
to 36 excluded studies and two related to the previously excluded
Publication or other bias ASCOT-LLA trial (Figure 1). Reasons for exclusion remained un-
A funnel plot was used to test for asymmetry, which represents changed and mainly included; treatment length not at least be-
the presence of publication bias based on the data for the primary ing one year, more than 10% of the population having existing
outcome of all-cause mortality (Sterne 2001). CVD and no relevant outcomes (to this review) being reported
(see Characteristics of excluded studies).

Figure 1. Study flow diagram for the update

Our update identified four new trials with 19,662 additional
participants (Bone 2007; CERDIA 2004; METEOR 2010; artery and one whose primary endpoint was change in bone den-
JUPITER 2008) bringing a total of 18 trials. Of the 18, trials, one sity, nine of the remaining trials chose a composite primary out-
tested two different interventions and for the purpose for meta come. Ten trials provided data on fatal and 11 on non-fatal CHD
analysis, this trial was counted as two trials (in total 19 trial arms) events, and five trials provided data on fatal and two on non-fa-
(CELL A 1996; CELL B 1996). In addition, our updated search tal CVD events. Ten trials reported on combined stroke events,
identified reporting of new follow-up data of the three of the 14 tri- five provided data on non-fatal and three on fatal stroke events.
als in the original review. (Adult Japanese MEGA Study; CARDS Fourteen trials provided data on cholesterol and 12 on adverse
2008; WOSCOPS). events. Four trials provided economic costings, (CARDS 2008;
The trials dated from 1994 to 2008 and were conducted world- JUPITER 2008; MRC/BHF Heart Protection; WOSCOPS) and
wide, mainly in industrially developed countries (Japan, USA, Eu- one (CELL A 1996; CELL B 1996) provided data on patient per-
rope and JUPITER which included sites in South America, Israel, ceived quality of life.
South Africa and Russia). Fourteen trials recruited patients with Excluding the four trials that solely recruited participants with
specific conditions: nine recruited participants with raised lipids, diabetes, 1% to 20% of the participants had diabetes. Excluding
four with diabetes, two with hypertension and one with microal- the two trials that recruited participants with hypertension, the
buminuria. remaining studies recruited 15% to 67% with hypertension. The
All tested the effectiveness of statins compared with placebo; nine proportion of participants smoking ranged from 10% to 45% in
tested pravastatin 10 mg to 40 mg per day; two atorvastatin 10 the 17 trials that provided these data. We were unable to ascertain
mg to 80 mg per day; two fluvastatin 40 mg to 80 mg per day; baseline lipid levels for three trials. Baseline total cholesterol levels
two lovastatin 20 mg to 40 mg per day; two rosuvastatin 20 mg ranged from 4.81 to 6.97 mmol/L (median 6.17 mmol/lL, and
to 40 mg per day; and the remaining two simvastatin 20 mg to LDL cholesterol from 2.8 to 4.95 mm/L (median 4.1mm/L).
40 mg per day (one of these had started patients on cerivastatin Risk of bias in included studies
0.4 mg per day which was replaced with simvastatin in August
2001). Five trials also included advice, counselling or information In general, there was low risk of bias (Figure 2; Figure 3) though
on health-behaviour modification such as diet, smoking cessation, all trials were either fully or partially funded by pharmaceutical
or exercise. companies (five by Bristol Myers and Squibb, three by Pfizer, four
In total, the 18 trials (with 19 trial arms) recruited 56,934 par- by Astra-Zeneca, two by Merck and one by Bayer, one by Bayer
ticipants and observed outcomes ranging from one to 5.3 years. and Merk, one by Pfizer, and the remaining by Sankyo Co Ltd).
The size of the population recruited ranged from 47to 17,802. Three (AFCAPS/TexCAPS 1998; ASPEN 2006; HYRIM 2007)
The mean age of the participants was 57 years (range 28-97 years), of the 19 trial arms did not provide adequate information on the
60.3% included male participants, and of the eight trials that re- methods used for randomisation, two of which had recruited more
ported on ethnicity, 85.9 % were Caucasian. than 2,000 participants. Eighteen trials used blinding to reduce
Three trials (AFCAPS/TexCAPS 1998; CARDS 2008; JUPITER bias, 15 of which used double-blinding methods. Thirteen used
2008) were stopped prematurely because significant reductions intention-to-treat analysis. The drop-out rates ranged from 2%
in primary composite outcomes between the intervention and to 30% for the 12 trials that reported on this. We judged 15 of
placebo had been observed. Overall, these trials had recruited 47% the trials to be free from selection bias. The MRC/BHF Heart
of the total study population and were stopped 1.4 to 3.0 years Protection Study (MRC/BHF Heart Protection) only provided
before the pre-specified end date. data on total CVD events for patients with diabetes in the primary
Data on all-cause mortality were provided in 11 trials. Excluding prevention group, and HYRIM reported outcomes on cholesterol
the four trials whose primary outcome was change in size of carotid on a subset of the population (46%) with no explanation as to
how the subset had been derived (HYRIM 2007).

Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality
item for each included study.

Figure 3. Methodological quality graph: review authors’ judgements about each methodological quality
item presented as percentages across all included studies.
The funnel plot for all-cause mortality showed no sign of asym-

metry (Figure 4).

Figure 4. Funnel plot of comparison: 2 Mortality and Morbidity, outcome: 2.1 Total Mortality.
Effects of interventions and 11 trials respectively. When pooled, a risk reduction in fatal
CHD events was observed; 251/23,019 (1.1%) statin group versus
All-cause mortality 306/23,075 (1.3%) placebo group; RR 0.82 (95% CI 0.70 to
Thirteen trials with 48,060 participants recruited reported on total 0.96) (Analysis 1.3). Evidence for a reduction in non-fatal CHD
mortality. During observation, 1077/24,408 (4.4%) died in the events was also found: 398/20,668 (1.9%) statin group versus 583/
statin group compared with 1223/23,652 (5.1%) in the placebo 20,309 (2.8%); RR 0.67 (95% CI 0.59 to 0.76). No significant
group; number needed to treat for five years: 96 (95% confidence heterogeneity was observed using a fixed-effect model for both
interval (CI) 64 to 244). Only the JUPITER trial showed strong analyses (Analysis 1.4).
evidence of a reduction in total mortality. When the data were
pooled using a fixed-effect model, a reduction that favoured statin
treatment by 14% was observed: (odds ratio (OR) 0.86, 95% CI Fatal and non-fatal CVD events
0.79 to 0.94). No heterogeneity was observed (Analysis 1.1).
Nine trials with 23,805 participants, representing 41.8% of the
total population, reported on combined fatal and non-fatal CVD
events. Four of the larger trials with 21,205 participants demon-
Fatal and non-fatal CHD events strated strong evidence of a reduction in this combined outcome.
Fourteen trials with 48,049 participants reported on combined In the pooled analysis using a fixed-effect model: 1103/11,892
fatal and non-fatal CHD events. Four trials showed evidence of a (9.3%) in the statin group versus 1455/11,913 (12.2%) in the
reduction in this combined outcome, which was maintained in the placebo group; RR 0.75 (95% CI 0.70 to 0.81). There was no
pooled analysis using a fixed-effect model: 820/24,217 (3.4%) in evidence of heterogeneity (Analysis 1.5).
the statin group versus 1114/23,832 (4.6%) in the placebo group. Five trials reported on fatal CVD events and two reported on
Overall NNT for five years: 56 (95% CI 46 to 75); risk ratio (RR) non-fatal CVD events. Reductions in risk were observed in both
0.73 (95% CI 0.67 to 0.80) (Analysis 1.2). these endpoints; fatal CVD events; 295/16,962 (17.4%) in the
Observations on fatal or non-fatal CHD events are based on 10 statin group versus 355/17,050 (20.8%) in the placebo group; RR

0.83 (95% CI 0.72 to 0.96) (Analysis 1.6); non-fatal CVD events Cholesterol
123/4,299 (3%) in the stain group versus 175/4,398 (4%) in the Fourteen trials provided data on total cholesterol, and 16 trials
placebo group, RR 0.77 (95% CI 0.62 to 0.96) (Analysis 1.7). No provided data on LDL cholesterol. For both endpoints, all trials
significant heterogeneity was observed using a fixed-effect model were able to demonstrate significant reductions. For total choles-
for both analyses. terol, a net difference of -1.05 mmol/L (95% CI -1.35 to -0.76
mmol/L) was observed (Analysis 2.1), and for LDL cholesterol a
net difference of -1.00 (95% CI -1.16 to -0.85 mmol/L) was ob-
served (Analysis 2.2). There was marked heterogeneity of effects
Fatal and non-fatal stroke events
in both analysis (I2 = 100% and 99%, respectively). It is likely that
Ten trials with 40,295 participants reported on combined fatal the heterogeneity is due to differences in the type of statin and
and non-fatal stroke events. Two trials that had been stopped pre- dosage used.
maturely demonstrated a significant reduction in this combined
outcome with the use of statins. This reduction was observed in
the pooled analysis using a fixed-effect model: 345/20,302 (17%) Adverse events
in the statin group versus 442/19,993 (22%) in the placebo group; Twelve trials provided data on adverse events. In total 10,838/
RR 0.78 (95% CI 0.68 to 0.89] (Analysis 1.8). 56,934 (19%) participants experienced an adverse event with ad-
Three trials with 27,238 participants reported on fatal stroke verse event rates ranging from 0% to 97%. Pooling the events
events, and five trials with 28,097 participants reported on non-fa- rates indicated no difference between the intervention and con-
tal stroke events. There was no observed difference in fatal stroke. trol groups with the use of statin using a fixed-effect model: RR
We applied a random-effects model due to significant heterogene- 1.00 (95% CI 0.97 to 1.03) (Analysis 3.1). No differences were
ity (I2 = 68%). Two of three trials had been prematurely stopped, observed between statin and control with the number of partic-
and the remaining trial (WOSCOPS) demonstrated a 43% in- ipants stopping statin treatment due to adverse events and those
crease in risk of fatal stroke, but this was not significant (Analysis admitted to hospital for an adverse event, though heterogeneity
1.9). Using a fixed-effect model, a significant risk reduction was was observed (Analysis 3.2; Analysis 3.3).
seen for non-fatal stroke events 193/14,243 (1.3%) in the statin Cancer: 2255/38,739 (5.8%) participants in 11 trials developed
group versus 276/13,852 (2%) in the placebo group; RR 0.69 cancer (Analysis 3.4). There was no evidence of any excess risk of
(95% CI 0.58 to 0.83) Analysis 1.10. cancers with a pooled estimate of RR 1.01 (95% CI 0.93 to 1.10)
and no heterogeneity.
Myalgia and rhabdomyolysis: 3551/37,939 participants in nine
Combined fatal and non-fatal CHD, CVD and stroke trials developed myalgia, but there was no evidence of excess risk
events with a pooled estimate of 1.03 (95% CI 0.97 to 1.09] with some
heterogeneity (I2 = 41%) (Analysis 3.5). Rhabdomyolysis was very
Only four trials with 35,254 participants reported a composite of rare, affecting three of 19,410 participants on statins in six trials
fatal and non-fatal events for CHD, CVD and stroke. All the trials reporting this outcome but with no evidence of any excess risk on
showed a significant reduction in this composite outcome with the statins: RR 1.00 (95% CI 0.23 to 4.38) (Analysis 3.6).The Heart
treatment of statins, which was maintained in the pooled analysis Protection Study outcomes for rhabdomyolysis were five cases in
and used a fixed model: 438/17,591 (2.4%%) events versus 678/ those on statins and three cases among controls, but these find-
17,663 (3.8%); RR 0.65 (95% CI 0.58 to 0.73) (Analysis 1.11). ings were not broken down by primary and secondary prevention.
Adding these additional events to the estimate above gives RR 1.31
(95% CI 0.47 to 3.62).
Type 2 diabetes: reporting of new occurrences of type 2 dia-
Revascularisation
betes was confined to only two trials, AFCAPS/TexCAPS 1998
Seven trials with 42,403 participants reported on the need and JUPITER 2008. Overall, 342/12,205 (2.8%) participants on
for revascularisation procedures during follow-up: 286/21,166 statins developed diabetes compared with 290/12202 (2.4%) par-
(1.4%) in the statin group versus 461/21237 (2.2%) in the placebo ticipants on control or placebo, with a relative risk of developing
group underwent either percutaneous transluminal coronary an- diabetes of 1.18 (95% CI 1.01 to 1.39). This excess risk of dia-
gioplasty (PTCA) or coronary artery bypass graft (CABG). Three betes was driven by the JUPITER trial, which used higher statin
of the larger trials were able to demonstrate fewer revascularisa- doses than the AFACPS/TexCAPS trial, which showed no effect
tion events in the intervention groups compared with the control on diabetes incidence (Analysis 3.7).
groups with the use of statins. This was maintained in the pooled Haemorrhagic stroke: only two trials reported haemorrhagic
analysis using a fixed-effect model: RR 0.62 (0.54 to 0.72) (Anal- stroke outcomes which occurred in 45/25634 (0.2%) participants
ysis 1.12). with a RR of 0.97 (95% CI 0.54 to 1.75) (Analysis 3.8).

Other adverse events: weak evidence was found for an increased (0.59 to 0.77) versus 0.73 (0.67 to 0.80) in all trials; adverse events
risk of liver enzyme elevations (10 studies) RR 1.16 (95% CI 0.87 RR 0.99 (0.96 to 1.02) versus 1.00 (0.97 to 1.03) in all trials.
to 1.54) (Analysis 3.9), renal dysfunction (four studies) RR 1.11
(95% CI 0.99 to 1.26) (Analysis 3.10), and arthritis (two studies)
RR 1.20 (95% CI 0.82 to 1.75) (Analysis 3.11).
DISCUSSION
The trials included in this systematic review showed reductions in
Treatment compliance
all-cause mortality, composite cardiovascular disease (CVD) end-
Of the eight trials that reported treatment compliance there was points, fatal and non-fatal CVD events considered separately, to-
no difference between the two groups (Analysis 4.1). In the statin tal and low density lipoprotein (LDL) cholesterol, and revascu-
group 77% participants and 70% in the placebo group complied larisations. These findings were associated with falls in total and
with treatment; RR 1.08 (0.98 to 1.18). LDL cholesterol in all trials reporting these outcomes. No excess
of combined adverse events, cancers, myopathy, rhabdomyolysis,
haemorrhagic stroke, liver enzyme elevation, renal dysfunction
Costs and arthritis were found, although not all trials reported fully on
Four trials reported on costs. WOSCOPS found that the use of adverse events. An increased risk of incident diabetes was found in
statin yielded substantial health benefits at a cost which was not the two trials reporting this outcome. There was limited evidence
prohibitive: an undiscounted gain of 2460 years of life at a cost of to suggest that the use of statins for primary prevention may be
£8,121 per life year gained (WOSCOPS). In the JUPITER trial, cost-effective. However, in light of new evidence derived from the
the authors estimated that rosuvastatin therapy was cost-effec- CTT Collaboration on primary prevention, there is a need to up-
tive, using a willingness-to-pay threshold of £31,882/QALY, statin date existing cost-effective analysis. Patient perceived quality of
therapy had a cost-effectiveness of £25,796/QALY for CHD and life was reported in only one trial, which showed limited benefit.
stroke prevention. (JUPITER 2008-Ohsfeldt 2010) The authors Sensitivity analysis suggested that early stopping of trials and size
of CARDS estimated the cost of managing CVD events would be of trial did not influence the overall results.
lower after five years for patients treated with atorvastatin com-
Although the trials intended to recruit only people without ev-
pared with those on placebo. The cost-effectiveness of atorvastatin
idence of CVD, some trials did include some participants with
10 mg/day would be £87,525/QALY at five years, with an incre-
CVD. Rather than exclude such trials, we set an arbitrary thresh-
mental cost of £2,320/QALY at 10 years. (CARDS 2008-Ramsay
old of 10% to avoid any major influence of effects of treatment
2008)
on those with existing CVD. A sensitivity analysis, excluding the
five trials that had up to 10% participants with clinical evidence of
CVD at baseline, showed very little difference between effect sizes
Patient quality of life
compared with all the trials included in this review. Our findings
There were no reliable data on patient quality of life reported by concur with previous systematic reviews (Brugts 2009; Ebrahim
trials. CELL A+B provided limited data on quality of life, sug- 1999; NICE 2006). However, previous systematic reviews have
gesting that the intervention of lifestyle advise plus pravastatin re- included trials where more than 10% of participants had a previ-
duced stress and sleeping problems. ous history of CVD which is reflected in their higher baseline all-
cause mortality event rates which were 1.4 per 100 person years
at risk (NICE 2006) and 1.7 per 100 person years (Brugts 2009)
Sensitivity analysis
compared with 1.0 per 100 person years in this review.
We were unable to locate any unpublished studies. As the study
The CTT Collaboration has published analyses focusing on the
quality was overall rated as good, for the update we confined our
comparison between high and low doses of statins which demon-
sensitivity analysis to comparing studies that were stopped early
strate that more intensive treatment lowers LDL cholesterol more,
and followed a protocol and to comparing large and small studies
resulting in greater benefits (CTT Collaboration 2010) with no
for total mortality and total CHD events. These analyses indicated
excess risk of non-vascular mortality. However, a increase in the
no change in the overall results in early stopping of trials and for
risk of myopathy and rhabdomyolysis in people treated with statins
study size for either outcome (Analysis 5.1; Analysis 5.2 Analysis
is confirmed, particularly among those treated with higher rather
5.3; Analysis 5.4).
than lower doses statins (Armitage 2007). Strong evidence of the
Excluding the five trials that included up to 10% participants with
absence of any adverse effects on cancer risk is also confirmed by a
clinical evidence of CVD (none of the trials published the sub-
further CTT Collaboration report (CTT Collaboration 2012b).
group without any evidence of CVD) demonstrates very similar
findings: total mortality RR 0.80 (95% CI 0.70 to 0.91) versus Our estimates of effects on CVD outcomes and on all-cause mor-
RR 0.86 (0.79 to 0.94) in all trials; total CHD events RR 0.68 tality on statins are in line with the recent CTT Collaboration re-

port (CTT Collaboration 2012a). The major finding of this new and will be important in determining wider use of statins (Smeeth
report is the benefits from statins at low levels of CVD risk: six 2012).
and 15 major vascular events would be avoided per 1000 people
treated for five years in the two lowest baseline risk categories (< All but one of the trials had some form of pharmaceutical industry
5% five-year risk, RR 0·57 (0·36 to 0·89) and 5% to 10% five-year sponsorship. It is now established that published pharmaceutical
risk RR 0·61 (0·50 to 0·74)) respectively (Figure 1, CTT report), industry-sponsored trials are more likely than non-industry-spon-
giving NNT values of 167 and 67 respectively. These NNTs are sored trials to report results and conclusions that favour drug over
well within the range considered worthwhile in primary preven- placebo due to biased reporting and/or interpretation of trial re-
tion (e.g. for treatment of hypertension). sults (Als-Nielsen 2003). The reporting of adverse events in these
trials is generally poor, with failure to provide details of severity
The individual patient data analyses conducted by the CTT Col- and type of adverse events or to report on health-related quality
laboration counter concerns about the interpretation of the ev- of life. However, it seems unlikely that any major life-threatening
idence of statins for primary prevention. First, the use of com- hazards associated with statin use exist. Potential non-fatal but se-
posite endpoints derived from different CVD outcomes is over- rious hazards of long-term statin use have not been assessed in trials
come since there is sufficient power to demonstrate benefits for (e.g. possible cognitive impairments suggested by one small trial:
individual CVD outcomes. Second, additional data on outcomes Muldoon 2000). We have focused on adverse events arising in ran-
are available for most trials, which reduces any effect of selective domised trial populations but these cannot adequately assess rare
reporting of outcomes. Third, similar benefits of statins were seen hazards, such as rhabdomyolysis. Large observational databases are
in trials that stopped early and in those running their planned useful for detecting rare hazards associated with use of statins but
course. Fourth, concerns about effects in low-risk groups, partic- a causal attribution is more difficult to establish (Hippsley-Cox
ularly women, are now demonstrated to be similar to those in 2010; Smeeth 2008).
other trial participants. Fifth, the benefits of statins outweigh any
risks of serious adverse effects since no excess of cancers was found Our previous conclusion urging caution in the use of statins in
and all-cause mortality was lower in those on statins. Thus, ear- people at low risk of cardiovascular events is no longer tenable
lier claims that statins provide no overall benefit in primary pre- in light of the CTT Collaboration findings. Several issues remain
vention in terms of all-cause mortality (Therapeutics Letter 2003; to be considered before widespread use of statins could be rec-
Therapeutics Letter 2010; Ray 2010) can no longer be substanti- ommended in people at low risk (Ebrahim 2012; Smeeth 2012).
ated. These include: i) the feasibility and desirability of having to treat
the majority of people over the age of 50 with a statin; ii) the cost-
Haemorrhagic stroke may be increased by use of statins with an an- effectiveness of such a strategy using a conventional healthcare de-
nual excess risk of 0.5 per 1000 people treated over five years per 1·0 livery system; iii) diversion of attention from achieving coverage
mmol/L LDL cholesterol reduction reported by the CTT Collab- in people at high risk of events; iv) use of alternative public health
oration. However, overall stroke events were reduced, indicating a strategies to lower blood cholesterol; v) the views of patients on
net benefit. This might not be the case in Asian populations where life-long drug therapy; and vi) limited evidence on less serious but
haemorrhagic stroke is more common than ischaemic stroke, and nonetheless potentially important adverse effects and quality of
where evidence of association between low blood cholesterol and life.
haemorrhagic stroke has been reported (Ebrahim 2006).
The National Institute for Health & Clinical Excellence UK
Our review, with sparse data, found an increased risk of type 2 (NICE) has provided some cost-effectiveness estimates based on
diabetes in those treated with statins: RR 1.18 (95% CI 1.01 to data to 2005 and conclude that an annual risk of a CHD event
1.39), which is greater than the that found in a more compre- ranging from 3% to 0.5%, the ranges of cost per quality adjusted
hensive meta-analysis using both published and unpublished data life year gained (QALY) gained were £10,000 to £31,000 at age
from 13 trials (both primary and secondary prevention) which re- 45 years, £13,000 to £40,000 at age 55 years using older generic
ported a relative risk of 1·09; 95% CI 1·02 to 1·17, with a num- statins (NICE 2006). Their guidance is to use statins “... as part
ber needed to harm of 255 people treated for four years to result of the management strategy for the primary prevention of CVD
in one case of diabetes (Preiss 2011; Sattar 2010). This increased for adults who have a 20% or greater 10-year risk of developing
risk of diabetes appears to be related to baseline fasting glucose CVD.” Evidence supporting the use of statins as part of an overall
levels and metabolic syndrome among participants randomised strategy of identification of people at high risk of CVD events and
to statins (Waters 2011). It can be argued that the overall small lowering blood pressure and blood cholesterol has been produced
proportion of people who develop diabetes when treated with a for low- and middle-income countries (Lim 2007) and is now
statin is outweighed by the benefits of statins (CTT Collaboration part of World Health Organization’s policy for CVD prevention
2012a). However, in the context of primary prevention, patients (WHO 2008b).
may expect not to be harmed in any way by ’preventive’ treat-
ments. Patient view points of such trade-offs remain to be assessed Low cost generic statins are now widely available and recent cost-

effectiveness studies show that statins are cost-saving in the USA their effects with statins in robust randomised trials given recent
even in people at low levels of predicted CHD risk. To gain maxi- evidence of large independent survival benefits of physical fitness in
mal impact from using statins, 64 million people in the USA (just those taking statins in a large prospective cohort study (Kokkinos
under half of the over 35 year old population) would need to be 2012). Relevant interventions might include nutrition education,
put on treatment at a cost of US$2,800 per QALY gained (Lazar exercise prescription, physical education curriculums that may be
2011). These cost-effectiveness estimates are likely to be better effective in changing lifestyle behaviours. (Jepson 2000) Studies of
for more potent statins and in lower cost health services. patient experiences and views on long-term use of statins are also
needed to improve adherence to treatment. It is likely that further
trials will be conducted in younger adults with adverse risk factor
profiles which are associated with higher lifetime CVD risk (Berry
AUTHORS’ CONCLUSIONS 2012) and also in children (de Ferranti 2008). It is important that
these trials examine comprehensively potential adverse effects of
Implications for practice statins and quality of life, reporting on them in an unbiased way.
The totality of evidence now supports the benefits of statins for
primary prevention. The individual patient data meta-analyses
now provide strong evidence to support their use in people at low
risk of cardiovascular disease. Further cost-effectiveness analyses ACKNOWLEDGEMENTS
are now needed to guide widening their use to these low risk
For the primary phase of this work we would like thank Gauri
groups.
Verma who contributed to selecting studies on statin treatment for
both primary and secondary prevention of cardiovascular disease
Implications for research undertaken in 2002. For the update of this review many thanks
In addition to the cost-effectiveness analyses referred to above, it go to Mrityunjay Kumar for helping to abstract data, and David
will be useful to study the effects of public health interventions that GriersonTaylor for diligently collecting data on share prices of the
attempt to alter diet and physical activity patterns and compare pharmaceutical companies that supported the included studies.
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Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
ACAPS 1994
Methods Randomised trial 4 x 4 factorial.
Participants 919 participants based in the USA aged 40 - 79 (mean age of 62); 52% men. None with
any clinical evidence of CVD
Interventions 20 mg lovastatin + 1 mg warfarin versus placebo followed up for 34 months
Outcomes Carotid atherosclerosis, cholesterol, fatal + non-fatal CHD events, stroke
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Low risk Blocked randomisation stratified by centre
bias)
Allocation concealment (selection bias) Unclear risk Not described
Blinding (performance bias and detection Low risk Carers and patients were blinded
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT, no drop-outs reported
All outcomes
Selective reporting (reporting bias) Low risk
Other bias Unclear risk Funded by pharmaceutical industry
Adult Japanese MEGA Study
Methods Randomised trial.
Participants 7832 participants with hypercholesterolaemia based in Japan aged 40-70 (mean age 59)
; 32% men. None with any clinical evidence of CVD
Interventions 10-20 mg pravastatin versus placebo; all participants got advice on diet; follow-up 5
years

Adult Japanese MEGA Study (Continued)
Outcomes Primary: composite of major CVD events, sudden cardiac death, angina and revascular-
isation. Single outcomes included: all-cause mortality, total CVD events, fatal and non-
fatal MI, stroke and TIA events, sudden cardiac death, angina and revascularisation,
cholesterol, adverse events
Notes
Risk of bias
Random sequence generation (selection Low risk Computerised randomisation by permuted block method.
bias)
Allocation concealment (selection bias) Low risk Central laboratory.
Blinding (performance bias and detection High risk Single blinded, endpoint committee was blinded only because
bias) investigators stated that placebo-controlled trials are regarded
All outcomes with suspicion by Japanese participants
Incomplete outcome data (attrition bias) Low risk ITT used 2% dropped out.
All outcomes
Selective reporting (reporting bias) High risk Not all adverse events reported. We wrote to the authors ask-
ing for clarity regarding data on serious events. The authors re-
sponded saying they were unable to send the data
Other bias Low risk Groups were comparable at baseline and includes all the major
prognostic factors
Funded by pharmaceutical industry.
AFCAPS/TexCAPS 1998
Participants 6606 participants in Texas, USA; mean age 58; 57.5% men; 89% Caucasian. None with
any clinical evidence of CVD
Interventions 20-40 mg lovastatin compared with placebo; follow-up for 5.2 years; all participants
received advice on diet
Outcomes Primary: composite of fatal and non-fatal MI and fatal CHD events. Single outcomes
included: all-cause mortality, fatal and non-fatal CVD + stroke events, heart failure and
adverse events
Notes Trial was stopped prematurely. To be terminated when 320 participants had experienced
primary outcome event. Stopped when 267 had done at 5.2 years

AFCAPS/TexCAPS 1998 (Continued)
Risk of bias
Random sequence generation (selection Unclear risk Not described

bias)
Blinding (performance bias and detection Low risk Double-blind: participants and personnel
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used no drop-outs reported
All outcomes
Selective reporting (reporting bias) Low risk Other than results for cholesterol
ASPEN 2006
Participants 2410 participants with type 2 diabetes based in 16 developed countries with mean age
60; 62.5% men; 84% Caucasian. < 10% with clinical evidence of CVD
Interventions 10 mg atorvastatin versus placebo; follow-up of 2.4 years (for primary prevention par-
ticipants)
Outcomes Primary: composite of fatal MI, stroke, sudden cardiac death, heart failure, CVD death.
Single outcomes included: non-fatal or silent MI + stroke, revascularisation, resuscitated
cardiac arrest, TIA, unstable angina, peripheral arterial disease, Ischaemic heart failure
and adverse events
Notes Primary prevention participants recruited 2-3 years into the study
Risk of bias

bias)

ASPEN 2006 (Continued)
Blinding (performance bias and detection Low risk Double-blind: participants and outcome assessors
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used 22% drop-outs reported
All outcomes
Selective reporting (reporting bias) Low risk Other than not providing results on adverse events for primary
prevention group
Bone 2007
Methods Randomised control trial.
Participants 626 Post-menopausal women aged 40-75 years with dyslipidaemia and no history of
CHD or diabetes. None with any clinical evidence of CVD
Interventions Atorvastatin (10/20/40/80 mg/day) with matching placebo. All patients were instructed
to be on NCEP ATP III diet
Outcomes Primary: Percentage change in lumbar spine bone marrow density Seconday: Percentage
change in femoral neck etc BMD by DXA. other; adverse events
Notes
Risk of bias
Random sequence generation (selection Low risk Computer-generated pseudo random code
bias)
Allocation concealment (selection bias) Low risk Random permuted blocks
Blinding (performance bias and detection Unclear risk States double blind but only reported that participants were
bias) blinded to interventions
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, 5% dropped out.
All outcomes
Selective reporting (reporting bias) Low risk All outcomes reported.

CAIUS 1996
Participants 305 participants with hypercholesterolaemia based in Italy with mean age 55; 53% men.
None with any clinical evidence of CVD
Interventions 40 mg pravastatin versus placebo; follow-up of three years.
Outcomes Slope of carotid artery, fatal and non-fatal MI, angina, revascularisations, cholesterol and
adverse events
Notes
Risk of bias
Random sequence generation (selection Low risk Independent co-ordinating centre controlled allocation
bias)
Allocation concealment (selection bias) Low risk Independent co-ordinating centre controlled allocation
Blinding (performance bias and detection Unclear risk Double-blind: participants and personnel
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, 13% dropped out
All outcomes
CARDS 2008
Participants 2838 participants with diabetes based in UK and Ireland aged 40-75 years (mean 61.7)
; 68% men; 94.5% Caucasian. None with any clinical evidence of CVD
Interventions 10 mg atorvastatin, all patients were given counselling on cessation of smoking; follow
up of 3.9-4 years
Outcomes Primary: composite of fatal and non-fatal MI, acute CHD death, resuscitated cardiac
arrest. Single outcomes included: all-cause mortality, fatal and non-fatal or silent MI
+ stroke, revascularisation, resuscitated cardiac arrest, total CVD events, adverse events
and cholesterol
Notes Trial stopped prematurely due to large beneficial treatment effect

CARDS 2008 (Continued)
Risk of bias
Random sequence generation (selection Low risk Computer-generated randomisation code

bias)
Allocation concealment (selection bias) Low risk Staff and patients unaware of computer-generated ran-
domisation code
Blinding (performance bias and detection Low risk Triple-blind: participants, personnel and outcome assessors
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, no drop-outs reported
All outcomes
CELL A 1996
Methods Randomised trial; 2 x 3 factorial design.
Participants 228 participants with hyperlipidaemia based in Sweden with a mean age of 49; 85%
men, <10% had clinical evidence of CVD
Interventions 10-40 mg pravastatin plus intensive dietary advice versus placebo; follow-up for 18
months
Outcomes Fatal MI, cholesterol, quality of life.
Notes
Risk of bias
Random sequence generation (selection Low risk Not described

bias)
Allocation concealment (selection bias) Low risk Randomisation performed separately for
each centre with numbers allocated to inter-
vention and control groups

CELL A 1996 (Continued)
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, 14.5% dropped out
All outcomes
Selective reporting (reporting bias) High risk Adverse events rates not provided for each
group
CELL B 1996
Methods Randomised trial; 2 x 3 factorial design.
Participants 227 participants with hyperlipidaemia based in Sweden with a mean age of 49; 85%
men, <10% had clinical evidence of CVD
Interventions 10-40 mg pravastatin plus dietary advice versus placebo; follow-up for 18 months
Outcomes Fatal MI, cholesterol, quality of life.
Notes
Risk of bias

bias)
Allocation concealment (selection bias) Low risk Randomisation performed separately for
each centre with numbers allocated to inter-
vention and control groups
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, 6% dropped out
All outcomes
Selective reporting (reporting bias) Unclear risk CVD and adverse events rates not provided
for each group

CERDIA 2004
Methods Parallel group randomised control trial.
Participants 250 patients with type 2 Diabetes aged 30-80 years. None with any clinical evidence of
CVD
Interventions 0.4 mg of Cerivastatin until 08/2001 then Simvastain 20 mg.
Outcomes Primary outcome: Change in mean common carotid intima media thickness (IMT) after
24 months of intervention. Secondary outcomes: Changes in Mean + maximum IMT
at 24 months, CVD events, amputation due to atherosclerotic disease, serum levels of
LDL and total cholesterol
Notes In August 2001, Cerivstatin was withdrawn from market.
Risk of bias
Random sequence generation (selection Low risk Predetermined computer-generated

bias) randomisation sequence in block of 10
Blinding (performance bias and detection Low risk States double blind but only reported that
bias) participants were blinded to interventions
All outcomes
Incomplete outcome data (attrition bias) High risk ITT not used, 27% dropped out.
All outcomes
Selective reporting (reporting bias) Low risk States double blind but unclear who was
blinded.
Other bias Unclear risk Comparable at baseline, including all major

prognostic group however its unclear if it was
valid and reliable method to determine out-
comes
Derosa 2003
Participants 47 participants with hypercholesterolaemia based in Italy with a mean age of 51; 46%
men. None with any clinical evidence of CVD
Interventions 80 mg fluvastatin versus placebo; all participants were given advice on diet and exercise
; follow-up for one year

Derosa 2003 (Continued)
Outcomes Adverse events, cholesterol.
Notes
Risk of bias
Random sequence generation (selection Low risk Envelopes containing randomisation codes prepared by statisti-
bias) cian
Allocation concealment (selection bias) Low risk Allocation code could only be identified by statistician and per-
son responsible for statistical analysis
Blinding (performance bias and detection Low risk Single blind: participants
bias)
All outcomes
All outcomes
HYRIM 2007
Methods Randomised trial 2 x 2 factorial design.
Participants 287 men with hypertension based in Norway aged 40-75 years (mean age 57). None
with any clinical evidence of CVD
Interventions 40 mg fluvastatin; follow-up four years.
Outcomes Primary: composite of fatal and non-fatal MI, + stroke, angina, sudden CHD death,
TIA and heart failure. MACE: composite of cardiac death, fatal and non-fatal MI and
revascularisation. Single outcomes included: adverse events, cholesterol
Notes
Risk of bias

bias)

HYRIM 2007 (Continued)
bias)
All outcomes
Incomplete outcome data (attrition bias) Unclear risk Not described and no drop-outs reported
All outcomes
Selective reporting (reporting bias) Low risk Mostly but not for adverse events and choles-
terol level at baseline and at 4-year follow-up
not provided
Other bias Unclear risk Groups comparable at baseline, including all

major prognostic factors, structured interview
for outcomes and side effects confirmed by
independent expert committee
JUPITER 2008
Participants 17,802 participants (intervention:8901, control 8901) > 50 years. None with any clinical
evidence of CVD
Interventions Rosuvastatin 20 mg daily.
Outcomes First occurrence of major cardiovascular event, revascularisation, hospital admission for
angina, MI, stroke, all-cause death, CVD death and adverse events
Notes Stopped early with a follow-up of 1.9 years.
Risk of bias
Random sequence generation (selection Low risk Randomisation done in block of 4, use of Interactive voice
bias) response system-generated allocation sequence
Allocation concealment (selection bias) Low risk Stratified according to the centre
Blinding (performance bias and detection Low risk Double blind, participants and outcomes assessed by end
bias) point committee
All outcomes
All outcomes

JUPITER 2008 (Continued)
Selective reporting (reporting bias) Low risk There was limited data on LDL and TC at the end of trial
Other bias High risk Groups comparable at baseline, including all major prog-
nostic factors, structured interview assessing outcomes and
adverse effects confirmed by independent expert commit-
tee. Trial was stopped early with a follow-up of 1.9 years.
Funded by pharmaceutical industry
KAPS 1995
Participants 447 men based in Finland aged 44-65 years (mean 57). < 10% with clinical evidence of
CVD
Interventions 40 mg pravastatin versus placebo; follow-up of 3 years.
Outcomes Carotid atherosclerotic progression, total mortality, fatal and non-fatal MI events, stroke,
adverse events, cholesterol, other cardiac death, revascularisations, non cardiac death and
heart failure
Notes
Risk of bias
Random sequence generation (selection Low risk Biostatistician prepared randomisation scheme
bias)
Allocation concealment (selection bias) Low risk Tablets were masked by pharmaceutical company
bias)
All outcomes
Incomplete outcome data (attrition bias) High risk ITT was not used, 17% patients dropped out
All outcomes

METEOR 2010
Participants 984 asymptomatic individuals with a mean age of 57 years. None with any clinical
evidence of CVD
Interventions Rosuvastatin 40 mg/ day.
Outcomes Primary: Mean of 12 Carotid Intima media (CIMT) thickness measurements. Secondary:
CIMT measurements of left and right common carotid artery. Other relevant outcomes:
adverse events, cholesterol levels
Notes
Risk of bias
Random sequence generation (selection Low risk Randomisation in block of 7 (5 to intervention and 5 to
bias) control)
Allocation concealment (selection bias) Low risk Blinded study medication
Blinding (performance bias and detection Low risk Blinding both to participants and personnel.
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used 25-6% dropped out.
All outcomes
MRC/BHF Heart Protection
Methods Randomised trial (2 x 2 factorial design).
Participants 3982 patients with no prior CHD with diabetes mellitus as a subset of 20,536 UK adults
aged 40-80 years
Interventions 40 mg simvastatin compared with placebo, follow-up 5.3 years for all participants
Outcomes Composite of coronary and vascular events, stroke, revascularisations
Notes
Risk of bias

MRC/BHF Heart Protection (Continued)

bias)
Allocation concealment (selection bias) Low risk Central telephone system used
Blinding (performance bias and detection Low risk Double blind: participants and outcome as-
bias) sessors
All outcomes
Incomplete outcome data (attrition bias) Unclear risk Not described

All outcomes
Selective reporting (reporting bias) High risk Only CVD event results provided for this
subgroup
Other bias Unclear risk Funded by pharmaceutical industry.
PHYLLIS 2004
Methods Randomised trial 4 x 4 factorial.
Participants 253 men and women aged 45-70 (mean age 58) with hypertension, hypercholestero-
laemia and asymptomatic carotid atherosclerosis based in Italy. None with any clinical
evidence of CVD
Interventions 25 mg hydrochlorothiazide + 40 mg pravastatin followed up for 2.6 years
Outcomes Primary outcomes: carotid atherosclerosis. Secondary outcomes: non-fatal MI, CVD
death, stroke, cholesterol and cancer
Notes
Risk of bias
Random sequence generation (selection Low risk Randomisation was computer-generated in blocks of
bias) 4
Blinding (performance bias and detection Low risk Double blind

bias)
All outcomes

PHYLLIS 2004 (Continued)
Incomplete outcome data (attrition bias) Low risk ITT used, 20% drop-outs reported
All outcomes
PREVEND IT 2004
Methods Randomised trial 2 x 2 factorial design.
Participants 864 participants with microalbuminuria based in Holland aged 28-75 years (mean age
51); 64.5% men; 96% Caucasian. < 10% with clinical evidence of CVD
Interventions 40 mg pravastatin versus placebo; follow-up 3.8 years.
Outcomes Primary outcome: composite of fatal and non-fatal CVD events. Single outcomes in-
cluded fatal CVD events, stroke, heart failure, non-fatal MI and cholesterol
Notes
Risk of bias
Random sequence generation (selection Low risk Randomisation was computer-generated.

bias)
Allocation concealment (selection bias) Low risk Participants randomised were allocated to a
treatment number
Blinding (performance bias and detection Low risk Double blind

bias)
All outcomes
Incomplete outcome data (attrition bias) Unclear risk ITT used but confined to CVD events, 6%
All outcomes dropped out

WOSCOPS
Participants 6595 men with hypercholesterolaemia based in Scotland aged 45-64 (mean age 55). <
10% with clinical evidence of CVD
Interventions 40 mg pravastatin versus placebo; follow-up 4.9 years.
Outcomes Primary outcome: composite of non-fatal MI and CHD death. Single outcomes included
total mortality, fatal CVD events, cholesterol, revascularisations, non-fatal MI and CHD
death and adverse events
Notes
Risk of bias
Random sequence generation (selection Low risk Blocks of random numbers and treatment assigned randomly
bias)
Allocation concealment (selection bias) Low risk All trial personnel remained unaware of the participant’s treat-
ment assignment throughout the study
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk ITT used, 30% drop-outs reported
All outcomes
BMD: bone mineral density

CHD: coronary heart disease
CIMT: carotid intima media thickness
CVD: cardiovascular disease
DXA: Dual-energy X-ray absorptiometry
ITT: intention-to-treat
LDL: low density lipoprotein
MI: myocardial infarction
TC: total cholesterol
TIA: transient ischaemic attack

Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Agewall 2006 Treatment length was less than a year
ALLHAT-LLT 2002 15% patients had history of CVD
Ames 2011 No relevant outcomes reported
Anderson 1993 No placebo - statin + antioxidant versus statin + antioxidant
ASCOT-LLA 2003 18% patients had history of CVD
ASTRONOMER 2010 Study is not a primary prevention
Bak 1998 Treatment length was less than a year
BCAPS 2001 11% patients had history of CVD
Boccuzzi 1991 Not a RCT - all participants were given Simvastatin
Branchi 1995 Control Group was not randomised
Byington 1993 Secondary prevention
CASHMERE 2007 Treatment length was less than a year
Cassader 1993 Treatment length was less than a year
CHALLENGER Patients with CHD were included in study
Chan 1996 Treatment length was less than a year
Chuengsamarn 2010 Study is not a RCT
CLIP 2002 Not a RCT - All participants were given Pravastatin
Cowan 2010 Follow-up duration was inadequate
Coylewright 2008 Secondary prevention
CRISP 1994 Treatment length was less than a year
CURVES 1998 No placebo - statin versus statin
Dangas 1999 Treatment length was less than a year

(Continued)
Davidson 1997 No placebo - statin versus statin
Duffy 2001 Treatment length was less than a year
Egashira 1994 Not a RCT - All participants were given Pravastatin
Eriksson 1998 No control group - Pravastatin vs. Cholestyramine
EXCEL 1990 Treatment length was less than a year
Faergeman 2009 Comparison of two statins/doses
FAST 2002 Over 40% had CVD and over 14% had CHD
Ferrari 1993 Treatment length was less than a year
Gentile 2000 Treatment length was only 24 weeks
Glasser 1996 Length of treatment was only 12 weeks
Gomez-Garcia 2007 Follow-up period was less than a year
Guisasola 2009 Study is not a RCT
Hokuriku NK-104 Study 02 Not a RCT - All participants were given intravasating
Hongo 2010 No placebo control group
Hufnagel 2000 Treatment length was less than a year
Italian Family Physician Not a RCT - open-labelled
J-LIT 2007 Study is not a RCT
Jardine 2006 Outcomes provided were aggregated. Unable to ascertain actual numbers for cardiac death and my-
ocardial infarction
JART 2011 Comparison was between two types of statin
JELIS 2009 No placebo/control group and study was a secondary prevention
Jones 1991 Treatment length was less than a year
Kappelle 2009 Treatment length was less than a year
KLIS 2000 Not randomised

(Continued)
Kojima 2010 Secondary prevention
Lemaitre 2002 Cohort study
Lin 2010 No relevant outcomes reported.
LIPID 2010 Secondary prevention
Mareev 2008 Previous history of cardiovascular disease in most patients
McDermott 2003 Participants were not randomised to statins or no statins
Mizuguchi 2008 Study outcomes are not relevant to current review.
Mohler 2003 Patients recruited had peripheral arterial disease
Mok 2009 Secondary prevention
Muldoon 1997 Treatment length is only six months
Nephrotic Syndrome Study Treatment length was less than a year
Ohta 2000 Treatment length was less than a year
Oi 1997 No placebo or control group
Olzowy 2007 Outcomes of the study are not relevant to review.
Ormiston 2003 Not a RCT - all participants were given statins
Pavia 2000 Intervention included Amlodipine
Pitt 1999 No placebo - statins versus angioplasty
POSCH 1990 Statins were not used
Pravastatin Multi 1993 Treatment length was less than a year
PROSPER 2002 More than 10% of the participants had CVD
Safaei 2007 Study is not a RCT
SANDS 2008 Comparison of two different treatment algorithms which included statins
Schmermund 2006 Comparision of 10 mg vs 80 mg of statin.

(Continued)
Sen 2000 Treatment length was less than a year
Sprecher 1994 Treatment length was less than a year
Stein 1997 Treatment length was less than a year
Su 2000 Treatment length was less than a year
Tanaka 2001 Treatment length was less than a year
Tarin 2010 Secondary prevention
Teixeira 2011 No relevant outcomes
Tekin 2008 Not randomised
Thomas 1993 Treatment length was less than a year
Thrombosis Prevention Statins were not used
Togha 2009 Patients had a chronic disease.
Tran 2007 The data are based on inadequate length of treatment
Wallace 2003 Treatment length was less than a year
Wu 2007 No comparison group
Yu-An 1998 Treatment length was less than one year
Zachoval 2000 Comparison of two statins
CHD: coronary heart disease

CVD: cardiovascular disease
RCT: randomised controlled trial
Characteristics of studies awaiting assessment [ordered by study ID]
Babes 2010
Methods RCT
Participants Young adults
Interventions Statin

Babes 2010 (Continued)
Outcomes Endothelial dysfunction
Notes We wrote on three separate occasions to the authors for further information on this study and did not receive a
response
RCT: randomised controlled trial

DATA AND ANALYSES
Comparison 1. Mortality and Morbidity
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Total Mortality 13 48060 Odds Ratio (M-H, Fixed, 95% CI) 0.86 [0.79, 0.94]
2 Total Number of CHD Events 14 48049 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.67, 0.80]
3 Number of Fatal CHD Events 10 46094 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.70, 0.96]
4 Number of Non-fatal CHD 11 40977 Risk Ratio (M-H, Fixed, 95% CI) 0.67 [0.59, 0.76]
Events
5 Total Number of CVD Events 9 23805 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.70, 0.81]
6 Number of Fatal CVD Events 5 34012 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.72, 0.96]
7 Number of Non-fatal CVD 2 8696 Risk Ratio (M-H, Fixed, 95% CI) 0.77 [0.62, 0.96]
Events
8 Total Number of Stroke Events 10 40295 Risk Ratio (M-H, Fixed, 95% CI) 0.78 [0.68, 0.89]
9 Number of Fatal Stroke Events 3 27238 Risk Ratio (M-H, Random, 95% CI) 0.63 [0.18, 2.23]
10 Number of Non-fatal Stroke 5 28097 Risk Ratio (M-H, Fixed, 95% CI) 0.69 [0.58, 0.83]
Events
11 Total Number of Fatal and 4 35254 Risk Ratio (M-H, Fixed, 95% CI) 0.65 [0.58, 0.73]
Non-fatal CHD, CVD and
Stroke Events
12 Number of Study 7 42403 Risk Ratio (M-H, Fixed, 95% CI) 0.62 [0.54, 0.72]
Participants who underwent
Revascularisation
Comparison 2. Lipids (mmol/L)
No. of No. of
1 Total Cholesterol (mmol/L) 14 34122 Mean Difference (IV, Random, 95% CI) -1.05 [-1.35, -0.76]
2 LDL Cholesterol (mmol/L) 16 41380 Mean Difference (IV, Random, 95% CI) -1.00 [-1.16, -0.85]
Comparison 3. Adverse Events
No. of No. of
1 Number of study participants 12 40716 Risk Ratio (M-H, Fixed, 95% CI) 1.00 [0.97, 1.03]
who had adverse events
2 Number of study participants 9 21642 Odds Ratio (M-H, Random, 95% CI) 0.86 [0.65, 1.12]
who stopped treatment due to
adverse events
3 Number of study participants 2 19707 Risk Ratio (M-H, Random, 95% CI) 0.74 [0.38, 1.41]
who were admitted to hospital
who developed cancer
who developed myalgia or
muscle pain
who developed rhabdomyolysis
7 Number of study participants 2 24407 Odds Ratio (M-H, Fixed, 95% CI) 1.18 [1.01, 1.39]
who developed diabetes
who developed haemorrhagic
stroke
9 Number of study participants 10 40094 Risk Ratio (M-H, Random, 95% CI) 1.16 [0.87, 1.54]
who had elevated liver enzymes
who developed renal disorder
11 Number of study participants 2 7586 Odds Ratio (M-H, Random, 95% CI) 1.20 [0.82, 1.75]
who developed arthritis
Comparison 4. Treatment Compliance
No. of No. of
1 Treatment Compliance 8 41712 Risk Ratio (M-H, Random, 95% CI) 1.08 [0.98, 1.18]
Comparison 5. Sensitivity Analysis
No. of No. of
1 Early stopping of trials and total 11 46811 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.74, 0.92]
mortality
1.1 trials stopped early 3 27245 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.72, 0.96]
1.2 trials with no early stop 8 19566 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.69, 0.98]
2 Early stopping of trials and total 14 48066 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.67, 0.80]
CHD events
2.1 trials stopped early 3 27265 Risk Ratio (M-H, Fixed, 95% CI) 0.68 [0.58, 0.79]
2.2 trials with no early stop 11 20801 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.69, 0.84]
3 Study Size for total Mortality 11 46811 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.74, 0.92]
3.1 Over 1000 participants 6 43754 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.74, 0.92]
3.2 Under 1000 participants 5 3057 Risk Ratio (M-H, Fixed, 95% CI) 0.95 [0.50, 1.82]
4 Study Size for total CHD events 14 48066 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.67, 0.80]
4.1 Over 1000 participants 6 43597 Risk Ratio (M-H, Fixed, 95% CI) 0.74 [0.67, 0.80]
4.2 Under 1000 participants 8 4469 Risk Ratio (M-H, Fixed, 95% CI) 0.59 [0.39, 0.90]

FEEDBACK
Failure to cite CTT paper and dangerously misleading press release, 22 February 2011
Summary
Clinical Trials Services Unit and Epidemiogical Studies Unit
The Discussion of your paper erroneously stated that the CTT collaborators had not published information about the proportional
and absolute benefits of statin therapy among people with no prior history of vascular disease, although these were published in The
Lancet in November 2010 (Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive LDL-lowering
therapy: meta-analysis of individual data from 170,000 participants in 26 randomised trials of statin therapy. Lancet 2010; 376: 1670-
81). It also stated that the CTT collaborators had been “unable to provide the relevant analysis for inclusion in our review”, but we are
not aware of having been asked by you (or anyone in your team) to provide such analyses, and wonder whether correspondence may
have gone astray.
We are concerned that these mis-statements in the Cochrane Collaboration paper (and some over-statements in the related press release,
such as the claim that “Given that low cholesterol has been shown to increase [our emphasis] the risk of death from other causes,
statins may do more harm than good in some patients”) are dangerously misleading for the public -as well as not meeting the Cochrane
Collaboration’s key principle of ‘keeping up to date’. Might it be possible for this Cochrane report to be corrected as a matter of
urgency?
Professor Colin Baigent, Professor of Epidemiology, MRC Scientist, Hon. Consultant in Public Health
Professor Rory Collins, BHF Professor of Medicine and Epidemiology
Reply
The recent CTT Lancet November 2010 paper was not available to our team at the time the review was completed and submitted
for publication to the Cochrane Database of Systematic Reviews. We agree that a data point in Figure 3 gives the proportional and
absolute effects on major vascular events of a 1mmol/l reduction in LDL cholesterol in trial participants without prior cardiovascular
disease. Our estimate of this effect and its precision is similar to the CTT estimate. I am surprised that CTT did not provide more
information on other outcomes among participants taking statins for primary prevention. In particular, others have raised the issue
of all-cause mortality in primary prevention trials (Ray et al, Arch Intern Med. 2010;170:1024-1031) and have expressed concerns
about an increased risk of diabetes in those taking statins (Sattar et al, Lancet 2010;375:735-42). We will, of course, include reference
to the CTT paper and will remove the text stating that CTT was “unable to provide the relevant analysis for inclusion in our review”.
It should be feasible to make these changes in the next issue. Work is underway to conduct a comprehensive update of this review as
soon as possible.
Following discussions with David Tovey and Rory Collins, the press release was withdrawn and a correction issued on 8 March 2011
from by David Tovey, Editor in Chief ’s office on the homepage of the Cochrane Library (http://www.thecochranelibrary.com/details/
editorial/1029211/Correction-by-David-Tovey.html). An email was sent to all recipients of that press release, and correction was
attempted of any existing versions of the press release that were still in circulation.
Shah Ebrahim, lead author of Statins for the Primary Prevention of Cardiovascular Disease and Coordinating Editor of the Cochrane
Heart Group
Contributors
Colin Baigant & Rory Collins, Shah Ebrahim

Further correspondence with CTT collaboration, 7 April 2011
Summary
22 February 2011
Taylor F et al. Statins for the primary prevention of cardiovascular disease.
Cochrane Database of Systematic Reviews 2011, Issue 1
The Discussion of your paper erroneously stated that the CTT collaborators had not published information about the proportional
and absolute benefits of statin therapy among people with no prior history of vascular disease, although these were published in The
Lancet in November 2010 (Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive LDL-lowering
therapy: meta-analysis of individual data from 170,000 participants in 26 randomised trials of statin therapy. Lancet 2010; 376: 1670-
81). It also stated that the CTT collaborators had been “unable to provide the relevant analysis for inclusion in our review”, but we are
not aware of having been asked by you (or anyone in your team) to provide such analyses, and wonder whether correspondence may
have gone astray.
We are concerned that these mis-statements in the Cochrane Collaboration paper (and some over-statements in the related press release,
such as the claim that “Given that low cholesterol has been shown to increase [our emphasis] the risk of death from other causes,
statins may do more harm than good in some patients”) are dangerously misleading for the public -as well as not meeting the Cochrane
Collaboration’s key principle of ‘keeping up to date’. Might it be possible for this Cochrane report to be corrected as a matter of urgency?
Colin Baigent & Rory Collins
Reply 2 March 2011
Re: Statins for the primary prevention of cardiovascular disease, Cochrane Database of Systematic Reviews 2011, Issue 1.
Thanks for your letter of 22 February 2011. The recent CTT Lancet November 2010 paper was not available to our team at the time
the review was completed and submitted for publication to the Cochrane Database of Systematic Reviews. We agree that a data point
in Figure 3 gives the proportional and absolute effects on major vascular events of a 1mmol/l reduction in LDL cholesterol in trial
participants without prior cardiovascular disease. Our estimate of this effect and its precision is similar to the CTT estimate. I am
surprised that CTT did not provide more information on other outcomes among participants taking statins for primary prevention. In
particular, others have raised the issue of all-cause mortality in primary prevention trials (Ray et al, Arch Intern Med. 2010;170:1024-
1031) and have expressed concerns about an increased risk of diabetes in those taking statins (Sattar et al, Lancet 2010;375:735-42).
We will, of course, include reference to the CTT paper and will remove the text stating that CTT was “unable to provide the relevant
analysis for inclusion in our review”. It should be feasible to make these changes in the next issue.
The press release was referring to the association of low blood cholesterol (not cholesterol lowering by statins) with haemorrhagic
stroke which has been shown by several observational cohorts, including a large Korean civil servants cohort (n=3900 haemorrhagic
strokes), but these associations may be confounded. It would obviously be of great value to have a more reliable estimate of this effect by
randomization to statins than that reported in the recent CTT paper (RR 1.12 (95% CI: 0.93, 1.35) per 1 mmol/L reduction in LDL
cholesterol, webfigure 8) which might be achieved if more trials provided this outcome. More robust estimates would be particularly
helpful for low and middle income countries where underlying rates of haemorrhagic stroke remain high and statins, as part of a
“polypill” strategy, are being promoted for primary prevention.
We are already working on a full update of the review and have 7,000 citations to work through inclusion/exclusion criteria. In addition
to the changes for the next issue, if you want I can arrange to have your letter and my response entered in the correspondence section
linked to the review. This would enable your concerns to be immediately linked to the review and be readily available to readers of the
review. Let me know your preference.
Shah Ebrahim
4 March 2011
Dear Shah
Thank you for your response. One quick point of clarification, the press release actually says “low cholesterol has been shown to
increase [my emphasis] the risk of death from other causes” which is clearly quite different from what you have written in the second
paragraph of your letter and is dangerously irresponsible. I wondered, therefore, if - before considering publication - you would like to
make this error clear in your letter and ensure that the statement in the press release is formally retracted.
Rory Collins
04 March 2011
Dear Rory
I agree the wording is quite wrong. The press statement has not been published, nor is it available to readers of the review itself. I will
add a sentence saying that a press release about the review contained a seriously misleading statement that “low cholesterol has been
shown to increase the risk of death from other causes”.
Shah Ebrahim
4 March 2011
Thank you for your proposal to modify your letter which is fine as far as it goes. The statement in this press release (which engendered
wide publicity) is, however, so dangerously wrong that I think the Cochrane Collaboration is obliged to issue a public retraction.
Please could you forward my correspondence to whoever is responsible for dealing with such serious misrepresentations within the
Collaboration?
Rory Collins
4 March 2011
In the first instance, if we have published something that is misleading or incorrect in the press release I would suggest that we issue a
correction in the release accompanying the next issue. I would like to explore with the writer of the release how this happened, as this
is the first time that we have had such a complaint in relation to a press release, to the best of my knowledge. Having said that I am
responsible for the sign off of press releases so that any error is entirely my responsibility.
I am making some enquiries as a matter of urgency and will let you all know when we have a proposed course of action.
David Tovey
4 March 2011
Shah Ebrahim has confirmed that the statement is wrong (see below) and, in public health terms, it is potentially a far more serious
misrepresentation than that of the risks of MMR by Wakefield and The Lancet. As a consequence, I think it requires an urgent and
specific response by the Cochrane Collaboration and should not just be “buried” in a routine press release.
Rory Collins
8 March 2011
This is to update you in relation to our current plans in relation to correction of the press release.
Firstly, we are will contact via email in the next 48 hours, all individuals and agencies that received the original press release for Issue
1 and explain the need for a correction of the offending sentence. Secondly, we will publish a correction on The Cochrane Library
homepage explaining the error. I anticipate that this will happen later today. Thirdly we will do our utmost to ensure that anywhere
where the press release is still “live”, it is modified to a more satisfactory form of words.
The Cochrane Collaboration sets a high value on quality, scientific rigour and transparency. In this instance we are grateful to you for
pointing out an error in the press release that had evaded our editorial system. Please be assured that we regarded this as a serious matter,
and have sought to implement visible and appropriate measures to correct the error. We have also learned lessons from the episode that
once implemented will reduce the chance of a similar event in the future.
David Tovey
10 March 2011
Thank you for taking some steps towards dealing with this problem as the errors of fact in both the press release, as well as those in
the related paper (see our original letter to Shah Ebrahim and his reply: attached), have had a damaging effect on public health (as
well as on the credibility of the Cochrane Collaboration). It is very much to your credit that you wish to take final responsibility (as
editor) for these errors, but should not the authors also take some of the responsibility (rather than just passing the buck) since they
presumably approved the press release which quotes them?
I have now had an opportunity to read your Correction on the Cochrane Library website and, though welcome, it seems to me that it
is incomplete (given the errors in the original paper) and, indeed, is misleadingly half-hearted. For example, Shah Ebrahim accepts in
his letter to us that, by contrast with what he had claimed in his paper, results for the highly statistical benefits in patients with no prior
cardiovascular disease (risk ratio for major vascular events: 0.75; 95% CI 0.69 - 0.82) had been published nearly 3 months beforehand.
Your Correction would have been an opportunity to put that straight, rather than to assert that such errors do “not impact in any way
on the validity of the accompanying Cochrane Review”. Similarly, please could you explain why the claim in the press release that “low
cholesterol has been shown to increase the risk of death from other causes, statins may do more harm than good” is, according to the
assertion in your correction, “irrelevant to the underlying question being evaluated”? This does not seem to be correct.
I’m sorry not to have replied to your letter sooner, but I was waiting to see the Correction before doing so and was looking for it
on the Cochrane Collaboration website, where it does not appear. As well as having it on the Cochrane Library website, would it
not be appropriate to put this Correction (or, preferably, a more accurate one) on the Cochrane Collaboration website (and any other
Cochrane websites), especially since the statin paper is one of its featured reviews?
I do hope that you will reconsider the partial (in more than one sense) attempt that you’ve made so far to redress the serious harm that
has been caused to public health by the Cochrane Collaboration and its misinterpretation of the available evidence (which does not
seem to be at all consistent with your key principles).
Rory Collins
10 March 2011
I suspect we have reached an impasse. I really don’t accept that the response was half-hearted. To repeat, we have placed a highly visible
correction on the homepage of the product that was the subject of the press release, we have sent an email to all recipients of that press
release, and we have sought to correct any existing versions of the press release that are still in circulation.
I, not the Co-ordinating Editor, sign off the press release, so this was my error alone. It was, as you pointed out, a seriously incorrect
message - implying that the very act of reducing your serum cholesterol might cause early death - and could, if acted upon have caused
public harm. For that reason I recognised the need to act decisively and swiftly to correct any wrong impression. I made the point in
the correction that the press release mistake was based on a misunderstanding of the Cochrane Review, which had explicitly explained
that any possible association was highly unlikely to be based on cause and effect. Therefore I believe it was correct to be clear that the
press release was distinct from the review.
I recognise that you have also raised questions in relation to the content of the review. As Shah describes in his response, he has taken on
board your comments, explained why the Lancet paper was not considered in the original published version, and has sought to amend
the review appropriately at the earliest opportunity. For technical /publication reasons there will be an inevitable but short delay before
the changes are published.
I am aware that you are unlikely to agree, but I am confident that our response to the questions you have raised in relation to the press
release and the review has been appropriate, open and positive.
David Tovey
11 March 2011
I’m extremely grateful both for your careful response to my email and for what you’ve been able to do to rectify this problem. I did
have a couple of questions in my previous email which I’d be grateful if you’d consider. First, might it be possible to put the Correction
on the Cochrane Collaboration website as well, since that would be an obvious place where people alerted by the original press release
would go? Second, why do you say in the Correction that the claim in the press release that “low cholesterol has been shown to increase
the risk of death from other causes, statins may do more harm than good” is “irrelevant to the underlying question being evaluated” by
this meta-analysis of whether statins do more harm than good? I had thought that this Correction would have provided an opportunity
to indicate that errors in the original paper would also be corrected at the earliest possible opportunity.
Again, thanks for taking the issue so seriously and for going as far as you have towards repairing the damage caused.
Rory Collins
Reply
See above
Contributors
Colin Baigent & Rory Collins, Shah Ebrahim

22nd Febuary 2012
Summary
Feedback: Dear respected authors and editors of the Cochrane Heart Group, First, in the abstract of the systematic review, statistically
significant relative risk reductions were reported for all-cause mortality, non-fatal CVD events, and revascularisations. However, I had
trouble applying this knowledge in practice because there was no mention of the absolute risk reduction or number needed to treat
associated with statin use in this clinical setting. I thought these two values would be of clinical relevance since the review defined
primary prevention as treating people without evidence of existing cardiovascular disease, who would be expected to have low baseline
risks. Furthermore, despite the statistically significant relative risk reductions of key outcomes without an increase in adverse events
found by this review, the authors advised caution before prescribing statins for primary prevention. This was a point of confusion for
me, as I could not understand how the authors came to that conclusion. I think that because many people in the world have only access
to the Cochrane abstracts and plain language summary, the rationale for the conclusions should be explicit to the reader. Lastly, on the
abstract page this review was assessed as up-to-date on September 7, 2007, even though it was published on January 19, 2011. I was
not sure if that was a mistake.
With Kind Regards,
Qiming Roger Wu
BSc, BSc(Pharm), RPh, MD Candidate
Submitter agrees with default conflict of interest statement: I certify that I have no affiliations with or involvement in any organization
or entity with a financial interest in the subject matter of my feedback.
Reply
Dear Qiming Roger Wu,
Thank you for your feedback on this review of statins for primary prevention of cardiovascular disease. You would like to see absolute
risk differences and numbers needed to treat. We have not provided these as they are often misleading in primary prevention. The
absolute levels of CVD risk used will depend on a) what is included in ’CVD’ (e.g. new angina cases, revasularisations), b) the population
in which you practice (CVD incidence varies markedly between countries), c) age group and sex of the population considered. The
relative risk reduction figure is stable across outcomes, populations, age and sex groups. The NNT is not and presenting several NNTs
is confusing for the reader.
You are concerned about why we recommend caution in using statins for primary prevention despite the statistically significant relative
risk reduction. This is because the quality of the trials is variable (early stopping, selective reporting of outcomes), many do not report
any adverse events (which is unlikely to be true), and guidelines in UK, USA and Europe do not recommend their use at levels below
20% 10-year risk of CVD. This is discussed in detail in the main text but not in the abstract for reasons of space. In the abstract we say:
’Other potential adverse events were not reported and some trials included people with cardiovascular disease. Only limited evidence
showed that primary prevention with statins may be cost-effective and improve patient quality of life.’ This gives some, but not all,
of the rationale for use with caution. You question whether the review is as out of date as it appears. I am afraid it is. This is because
doing a Cochrane review on statins requires searching for relevant papers - in this case we had to sift through thousands of abstracts of
papers, retrieve hundreds of full papers, assess them in duplicate to reach our final 14 trials for consideration. This takes time and in
this case was made worse as the key authors were relocated to work in India on another project that took priority over this review. We
have conducted an update and hope that this will be published before the end of 2012.
Thank you for your interest in our work.
Best wishes, Shah Ebrahim
Contributors
Qiming Yu, Shah Ebrahim

WHAT’S NEW
Last assessed as up-to-date: 1 January 2012.
Date Event Description
4 December 2012 New citation required and conclusions have changed This update includes 4 new studies and updated date
from 3 studies and our conclusions have changed
18 June 2012 New search has been performed This review has been updated incorporating findings
from the Cholesterol Treatment Trialists Collaboration
individual patient data meta-analyses that extend the
findings on benefits of statins to people at lower risk of
major cardiovascular events than previously established.
Conclusions have been changed
HISTORY
Protocol first published: Issue 2, 2004
Review first published: Issue 1, 2011
Date Event Description
10 April 2012 New citation required and conclusions have changed New search to January 2012 found four new trials and pub-
lished follow-up data on three existing trials. Results and
conclusion have changed in light of the new evidence
10 April 2012 Feedback has been incorporated Feed back incorporated.
4 July 2011 Amended Rectified minor error in reporting of all-cause mortality data
in main text
7 April 2011 Amended Converted to new review format
7 April 2011 Feedback has been incorporated Correspondence with CTT collaboration added
8 March 2011 Feedback has been incorporated Removed text indicating CTT collaboration had not pro-
vided relevant data. Included citation to recent CTT collab-
oration paper which gives additional confirmation of ben-
efits of statins in primary prevention. Added in response to
CTT collaboration correspondence (see Feeback)

CONTRIBUTIONS OF AUTHORS
Professor Shah Ebrahim and Professor George Davey Smith: Origination of idea, preparation of review on which this review is based,
control of content.
Fiona Taylor: Assessed relevance and quality of papers, extracted data, analysed data and prepared the manuscript.
Mark Huffman: Helped screen abstracts for the update, contributed to the analysis and interpretation of data for the update.
Ana Macedo: Abstracted data for the update, helped assess adverse events and wrote to authors.
Kirsten Ward: Obtained papers, assessed relevance and quality of papers, extracted data, organised and analysed data.
Theresa Moore: Contributed to the early work on this review in addition to screening of abstracts for the update
Margaret Burke: Developed search strategy, ran searches and assessed relevance of papers.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• Department of Social Medicine, University of Bristol, UK.
External sources
• Department of Health Funding for the Cochrane Heart Group, UK.
INDEX TERMS
Medical Subject Headings (MeSH)

Cardiovascular Diseases [blood; ∗ prevention & control]; Cause of Death; Cholesterol, HDL [blood]; Cholesterol, LDL [blood];
Hydroxymethylglutaryl-CoA Reductase Inhibitors [adverse effects; ∗ therapeutic use]; Primary Prevention; Randomized Controlled
Trials as Topic
MeSH check words

Adult; Humans


Statin As Primary Prevention in CVD

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Statins for the primary prevention of cardiovascular disease

Statins for the primary prevention of cardiovascular disease (Review)

Statins for the primary prevention of cardiovascular disease (Review) i

Statins for the primary prevention of cardiovascular disease

Editorial group: Cochrane Heart Group.

PLAIN LANGUAGE SUMMARY

Statins for the primary prevention of cardiovascular disease (Review) 2

Statins for the primary prevention of cardiovascular disease (Review) 3

Criteria for considering studies for this review

Statins for the primary prevention of cardiovascular disease (Review) 4

Statins for the primary prevention of cardiovascular disease (Review) 5

Statins for the primary prevention of cardiovascular disease (Review) 6

Statins for the primary prevention of cardiovascular disease (Review) 7

Statins for the primary prevention of cardiovascular disease (Review) 8

Statins for the primary prevention of cardiovascular disease (Review) 9

The funnel plot for all-cause mortality showed no sign of asym-

Statins for the primary prevention of cardiovascular disease (Review) 10

Statins for the primary prevention of cardiovascular disease (Review) 11

Statins for the primary prevention of cardiovascular disease (Review) 12

Statins for the primary prevention of cardiovascular disease (Review) 13

Statins for the primary prevention of cardiovascular disease (Review) 14

Tekin 2008 {published data only} Additional references

Higgins 2011 LaRosa 1999

Statins for the primary prevention of cardiovascular disease (Review) 28

Statins for the primary prevention of cardiovascular disease (Review) 29

Characteristics of included studies [ordered by study ID]

Methods Randomised trial 4 x 4 factorial.

Interventions 20 mg lovastatin + 1 mg warfarin versus placebo followed up for 34 months

Outcomes Carotid atherosclerosis, cholesterol, fatal + non-fatal CHD events, stroke

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Unclear risk Not described

Selective reporting (reporting bias) Low risk

Other bias Unclear risk Funded by pharmaceutical industry

Adult Japanese MEGA Study

Methods Randomised trial.

Statins for the primary prevention of cardiovascular disease (Review) 30

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Low risk Central laboratory.

Methods Randomised trial.

Statins for the primary prevention of cardiovascular disease (Review) 31

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described

Allocation concealment (selection bias) Unclear risk Not described

Other bias Unclear risk Funded by pharmaceutical industry

Methods Randomised trial.

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described

Allocation concealment (selection bias) Unclear risk Not described

Statins for the primary prevention of cardiovascular disease (Review) 32

Other bias Unclear risk Funded by pharmaceutical industry

Methods Randomised control trial.

Bias Authors’ judgement Support for judgement

Allocation concealment (selection bias) Low risk Random permuted blocks

Selective reporting (reporting bias) Low risk All outcomes reported.

Other bias Unclear risk Funded by pharmaceutical industry

Statins for the primary prevention of cardiovascular disease (Review) 33

Methods Randomised trial.

Interventions 40 mg pravastatin versus placebo; follow-up of three years.

Bias Authors’ judgement Support for judgement