Burden and predictors of statin use in primary and secondary prevention of atherosclerotic vascular disease in the US: From the National Health and Nutrition Examination Survey 2017-2020

Document Type



Office of the Provost; Cardiology


Aims: To assess the current state of statin use, factors associated with non-use, and estimate the burden of potentially preventable atherosclerotic cardiovascular diseases (ASCVD) events.
Methods and results: Using nationally representative data from the 2017 to 2020 National Health and Nutrition Examination Survey, statin use was assessed in primary prevention groups: high ASCVD risk ≥ 20%, LDL-cholesterol (LDL-C) ≥ 190 mg/dL, diabetes aged 40-75 years, intermediate ASCVD risk (7.5 to <20%) with ≥1 ASCVD risk enhancer and secondary prevention group: established ASCVD. Atherosclerotic cardiovascular disease risk was estimated using pooled cohort equations. We estimated 70 million eligible individuals (2.3 million with LDL-C ≥ 190 mg/dL; 9.4 million with ASCVD ≥ 20%; 15 million with diabetes and age 40-75years; 20 million with intermediate ASCVD risk and ≥1 risk enhancers; and 24.6 million with established ASCVD), about 30 million were on statin therapy. The proportion of individuals not on statin therapy was highest in the isolated LDL-C ≥ 190 mg/dL group (92.8%) and those with intermediate ASCVD risk plus enhancers (74.6%) followed by 59.4% with high ASCVD risk, 54.8% with diabetes, and 41.5% of those with established ASCVD groups. Increasing age and those with health insurance were more likely to be on statin therapy in both the primary and secondary prevention categories. Individuals without a routine place of care were less likely to be on statin therapy. A total of 385 000 (high-intensity statin) and 647 000 (moderate-intensity statin) ASCVD events could be prevented if all statin-eligible individuals were treated (and adherent) for primary prevention over a 10-year period.
Conclusion: Statin use for primary and secondary prevention of ASCVD remains suboptimal. Bridging the therapeutic gap can prevent ∼1 million ASCVD events over the subsequent 10 years for the primary prevention group. Social determinants of health such as access to care and healthcare coverage were associated with less statin treatment. Novel interventions to improve statin prescription and adherence are needed.


This work was published before the author joined Aga Khan University.

Publication (Name of Journal)

European journal of preventive cardiology