Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is high or moderate to high where GRADE has been performed and there is no difference in effectiveness between the intervention and comparison for key outcomes.
Population: People with established CVD
Intervention: High-intensity statin ᵃ
Comparison: Medium-intensity statin ᵃ
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
All-cause mortality: all studies ᵇ | No statistically significant difference | High |
CV mortality: all studies ᵇ | No statistically significant difference | High |
Nonfatal myocardial infarction: all studies ᵇ | Favors intervention | High |
Stroke: all studies ᵇ | No statistically significant difference | High |
Myalgia: all studies ᵇ | Favors comparison | High |
Rhabdomyolysis: all studies ᵇ | Favors comparison | High |
Liver adverse events: all studies ᵇ | Occurs more commonly with high intensity statins compared with medium intensity statins (favors comparison) | Moderate |
New-onset diabetes ᵇ | No statistically significant difference | High |
Recommendations as stated in the source guideline The National Institute of Health and Care Excellence (NICE) 2023 guideline on lipid modification recommends the following: Start statin treatment in people with CVD with high-dose atorvastatin ᶜ. Use a lower dose of atorvastatin if any of the following apply: potential drug interactions high risk of adverse effects patient preference.
Note Due to the reduction in nonfatal myocardial infarction with high-intensity statin, the guideline group felt this to be the most cost effective option. The guideline group noted a consistent higher rate of adverse events for high-intensity simvastatin compared with other higher-intensity statins. ᵃ NICE defines statin intensities as follows: Low intensity = LDL-cholesterol reduction of 20%–30% Medium intensity = LDL-cholesterol reduction of 31%–40% High intensity = greater than 40% LDL-cholesterol reduction ᵇ The source material for this table (table 46 in the full text document) includes subgroup analyses which have not been listed here. ᶜ See guideline for their recommendation on starting dose of atorvastatin.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes.
Population: People with established CVD
Intervention: High-intensity statin ᵃ
Comparison: Low-intensity statin ᵃ
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
All-cause mortality | Favors intervention | Low |
CV mortality | No statistically significant difference | Moderate |
Nonfatal myocardial infarction | No statistically significant difference | Moderate |
Stroke | No statistically significant difference | Low |
Myalgia | No statistically significant difference | Low |
Rhabdomyolysis | No statistically significant difference | Very Low |
Liver adverse events | Occurs more commonly with high-intensity statin compared with low-intensity statin (favors comparison) | Moderate |
Recommendations as stated in the source guideline The National Institute of Health and Care Excellence (NICE) 2023 guideline on lipid modification recommends the following: Start statin treatment in people with CVD with high-dose atorvastatin.ᵇ Use a lower dose of atorvastatin if any of the following apply: potential drug interactions high risk of adverse effects patient preference.
Note The guideline development group notes that the evaluation of individual outcomes may underestimate the total clinical benefit of statins. The guideline compares many different intensities of statin. Overall, the guideline development group felt the evidence (clinical and cost-effectiveness) for reduction in nonfatal myocardial infarction was best for high-intensity statins. ᵃ NICE defines statin intensities as follows: Low intensity = LDL-cholesterol reduction of 20%–30% Medium intensity = LDL-cholesterol reduction of 31%–40% High intensity = greater than 40% LDL-cholesterol reduction ᵇ See guideline for their recommendation on starting dose of atorvastatin.
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- Is there randomized controlled trial evidence to support the use of statins for the primary prevention of cardiovascular disease?
- How do fibrates compare with placebo for primary prevention of cardiovascular disease events?
- What are the effects of PCSK9 monoclonal antibodies for preventing cardiovascular disease?
- How do PCSK9 monoclonal antibodies compare with ezetimibe and/or statin for prevention of cardiovascular disease?
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