Trends and inequalities in statin use for the primary and secondary prevention of cardiovascular disease between 2009 and 2021 in England: a series of cross-sectional and cohort studies

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Introduction: Previous studies suggest that inequalities in statin prescribing exist for the primary and secondary prevention of cardiovascular disease (CVD), but it is unclear where along the pathway, from recognition of risk through to prescribing and continuation, these inequalities manifest. We aimed to investigate trends and inequalities in statin use for primary and secondary prevention of CVD. Methods: We conducted a historical cohort study of 5 million adults aged 25 years or older, randomly sampled from the Clinical Practice Research Datalink linked to Hospital Episode Statistics in England between 2009 and 2021. We calculated the monthly proportion of current statin users. Using logistic regression and Cox modelling, we calculated adjusted ORs (aORs) for statin initiation and adjusted HRs (aHRs) for CVD, statin discontinuation and reinitiation. Results: In our primary prevention prevalence cohort (n=4 597 500), the overall monthly proportion of individuals prescribed statins increased from 22.3% in 2009 to 35.6% in 2021 among those aged 70+ years and was stable in other age groups. In our secondary prevention prevalence cohort (n=406 746), the monthly proportion of statin users was higher in all age groups (eg, increasing from 68.1% to 73.7% over the same period in those aged 70+ years). Between 2009 and 2021, women (aOR 0.70, 95% CI 0.68 to 0.72) and people of Black ethnicity (aOR 0.71, 95% CI 0.65 to 0.77) were less likely to be initiated on statins compared with those of White ethnicity for secondary prevention. Statin discontinuation was most likely among women (aHR 1.08, 95% CI 1.06 to 1.11), Black people (aHR 1.76, 95% CI 1.65 to 1.89) and the most deprived group (aHR 1.08, 95% CI 1.04 to 1.12) compared with men, White people and the least deprived group, respectively, for secondary prevention, with similar associations seen for primary prevention for ethnicity and deprivation. Conclusions: Statin use remains suboptimal, and inequalities, particularly among women, people of Black ethnicity and those in the most deprived socioeconomic groups, persist across multiple stages of statin use for both primary and secondary prevention. Strategies are needed specifically targeting these patient groups to reduce these inequalities.

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