26th October 2018, Volume 131 Number 1484

Nick Wilson, Amanda C Jones, Nhung Nghiem, Tony Blakely

Recent systematic review evidence on statins A systematic review and meta-analysis has recently been published in the Journal of the American Medical Association (JAMA) by Navarese et al.1 The authors…

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Given that it is very well proven that statins reduce the risk of premature death, in this article we examine how the use of these medicines may be improved for primary prevention of cardiovascular disease (CVD) in New Zealand. We suggest the need to explore such options as fixed-dose combination pills containing statins, three-drug polypills, behind-the-counter dispensing and six-month prescriptions. But in addition to pharmacological prevention of CVD, there is a need for improved population-wide changes to the environment. These include adopting policies to improve tobacco control, the nutrition environment (eg, particularly around sodium), alcohol control, and making walking and cycling easier options.


There is new evidence from a very large systematic review and meta-analysis (Navarese et al 2018), that using statins for reducing levels of low-density lipoprotein cholesterol reduces the risk of premature death. In this viewpoint article we consider the implications of this new evidence for New Zealand but also examine how the use of statins may be improved for primary prevention of cardiovascular disease (CVD) in this country. We suggest the need to explore such options as fixed-dose combination pills containing statins, three-drug polypills, behind-the-counter dispensing and six-month prescriptions. But in addition to pharmacological prevention of CVD, there is a need for improved population-wide changes to the environment. These include adopting policies to improve tobacco control, the nutrition environment (eg, particularly around sodium), alcohol control and making walking and cycling easier options.

Author Information

Nick Wilson, Department of Public Health, University of Otago Wellington, Wellington;
Amanda C Jones, Department of Public Health, University of Otago Wellington, Wellington;
Nhung Nghiem, Department of Public Health, University of Otago Wellington, Wellington;
Tony Blakely. Department of Public Health, University of Otago Wellington, Wellington.


Professor Nick Wilson, Department of Public Health, University of Otago, Mein St, Newtown, Wellington.

Correspondence Email


Competing Interests



  1. Navarese EP, Robinson JG, Kowalewski M, Kolodziejczak M, Andreotti F, Bliden K, Tantry U, Kubica J, Raggi P, Gurbel PA. Association Between Baseline LDL-C Level and Total and Cardiovascular Mortality After LDL-C Lowering: A Systematic Review and Meta-analysis. JAMA 2018; 319:1566–79.
  2. Ministry of Health. Cardiovascular Disease Risk Assessment and Management for Primary Care. Wellington: Ministry of Health. http://www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care 2018.
  3. Jackson R, Barham P, Bills J, Birch T, McLennan L, MacMahon S, Maling T. Management of raised blood pressure in New Zealand: a discussion document. BMJ 1993; 307:107–10.
  4. Robinson T, Jackson R, Wells S, Kerr A, Marshall R. An observational study of how clinicians use cardiovascular risk assessment to inform statin prescribing decisions. N Z Med J 2017; 130:28–38.
  5. Pylypchuk R, Wells S, Kerr A, Poppe K, Riddell T, Harwood M, Exeter D, Mehta S, Grey C, Wu BP, Metcalf P, Warren J, Harrison J, Marshall R, Jackson R. Cardiovascular disease risk prediction equations in 400 000 primary care patients in New Zealand: a derivation and validation study. Lancet 2018; 391:1897–907.
  6. Global Burden of Disease Study. Country Profile: New Zealand [2016 mortality data]. Seattle, Washington: Institute for Health Metrics and Evaluation. http://www.healthdata.org/new-zealand 
  7. Auckland UniServices Limited. “Variation in Medicines Use by Ethnicity: A Comparison between 2006/7 and 2012/13: Final Report Prepared for PHARMAC.” Auckland: University of Auckland, January 2018.
  8. Schilling C, Knight J, Mortimer D, Petrie D, Clarke P, Chalmers J, Kerr A, Jackson R. Australian general practitioners initiate statin therapy primarily on the basis of lipid levels; New Zealand general practitioners use absolute risk. Health Policy 2017; 121:1233–39.
  9. Wells S, Poppe K, Selak V, Kerr A, Pylypchuk R, Wu B, Chan WC, Grey C, Mehta S, Gentles DG, Jackson R. Is general practice identification of prior cardiovascular disease at the time of CVD risk assessment accurate and does it matter? N Z Med J 2018; 131:10–20.
  10. Fuller RH, Perel P, Navarro-Ruan T, Nieuwlaat R, Haynes RB, Huffman MD. Improving medication adherence in patients with cardiovascular disease: a systematic review. Heart 2018; (E-publication 25 March).
  11. Australian Government Department of Health. The pharmaceutical benefits scheme. http://www.pbs.gov.au/browse/body-system?depth=4&codes=c09dx#c09dx
  12. Selak V, Harwood M, Raina Elley C, Bullen C, Wadham A, Parag V, Rafter N, Arroll B, Bramley D, Crengle S. Polypill-based therapy likely to reduce ethnic inequities in use of cardiovascular preventive medications: Findings from a pragmatic randomised controlled trial. Eur J Prev Cardiol 2016; 23:1537–45.
  13. World Heart Federation. Polypill News: April 2016.
  14. Selak V, Webster R. Polypills for the secondary prevention of cardiovascular disease: effective in improving adherence but are they safe? Ther Adv Drug Saf 2018; 9:157–62.
  15. Selak V, Bullen C, Stepien S, Arroll B, Bots M, Bramley D, Cass A, Grobbee D, Hillis GS, Molanus B, Neal B, Patel A, Rafter N, Rodgers A, Thom S, Tonkin A, Usherwood T, Wadham A, Webster R. Do polypills lead to neglect of lifestyle risk factors? Findings from an individual participant data meta-analysis among 3140 patients at high risk of cardiovascular disease. Eur J Prev Cardiol 2016; 23:1393–400.
  16. TeArai BioFarma. “New Zealand Is a Step Closer to Funding the Cardiovascular Polypill | Te Arai BioFarma.” News, January 31, 2018.
  17. Wilson N, Selak V, Blakely T, Knight J, Nghiem N, Leung W, Clarke P, Jackson R. Decision-making in an era of cancer prevention via aspirin: New Zealand needs updated guidelines and risk calculators. N Z Med J 2016; 129(1431):85–92.
  18. Sood N, Sun E, Zhuo X. Behind-the-counter statins: a silver bullet for reducing costs and increasing access? Health Serv Res 2012; 47:174–87.
  19. Batal HA, Krantz MJ, Dale RA, Mehler PS, Steiner JF. Impact of prescription size on statin adherence and cholesterol levels. BMC Health Serv Res 2007; 7:175.
  20. Doble B, Payne R, Harshfield A, Wilson ECF. Retrospective, multicohort analysis of the Clinical Practice Research Datalink (CPRD) to determine differences in the cost of medication wastage, dispensing fees and prescriber time of issuing either short (<60 days) or long (>/=60 days) prescription lengths in primary care for common, chronic conditions in the UK. BMJ Open 2017; 7:e019382.
  21. Abukres SH, Hoti K, Hughes JD. Continued Dispensing: what medications do patients believe should be available? PeerJ 2015; 3:e924.
  22. Ju A, Hanson CS, Banks E, Korda R, Craig JC, Usherwood T, MacDonald P, Tong A. Patient beliefs and attitudes to taking statins: systematic review of qualitative studies. Br J Gen Pract 2018; 68:e408–e19.
  23. Crengle S, Luke JN, Lambert M, Smylie JK, Reid S, Harre-Hindmarsh J, Kelaher M. Effect of a health literacy intervention trial on knowledge about cardiovascular disease medications among Indigenous peoples in Australia, Canada and New Zealand. BMJ Open 2018; 8:e018569.
  24. Blakely T, Cobiac LJ, Cleghorn CL, Pearson AL, van der Deen FS, Kvizhinadze G, Nghiem N, McLeod M, Wilson N. Health, health inequality, and cost impacts of annual increases in tobacco tax: Multistate life table modeling in New Zealand. PLoS Med 2015; 12:e1001856. [Correction at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.2211].
  25. Thornley L, Edwards R, Waa A, Thomson G. Achieving Smokefree Aotearoa by 2025. University of Otago, ASPIRE 2025, Quitline, Hapai Te Hauora, 2017. http://aspire2025.files.wordpress.com/2017/08/asap-main-report-for-web2.pdf
  26. van der Deen FS, Wilson N, Cleghorn CL, Kvizhinadze G, Cobiac LJ, Nghiem N, Blakely T. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control 2018; 27:278–86.
  27. Cleghorn CL, Blakely T, Kvizhinadze G, van der Deen FS, Nghiem N, Cobiac LJ, Wilson N. Impact of increasing tobacco taxes on working-age adults: short-term health gain, health equity and cost savings. Tob Control 2017; (E-publication 18 November).
  28. Pearson AL, Cleghorn CL, van der Deen FS, Cobiac LJ, Kvizhinadze G, Nghiem N, Blakely T, Wilson N. Tobacco retail outlet restrictions: health and cost impacts from multistate life-table modelling in a national population. Tob Control 2016;(E-publication 22 September).
  29. Nghiem N, Cleghorn CL, Leung W, Nair N, van der Deen FS, Blakely T, Wilson N. A national quitline service and its promotion in the mass media: modelling the health gain, health equity and cost-utility. Tob Control 2018; 27:434–41.
  30. Mahesh R, Vandevijvere S, Dominick C, Swinburn B. Relative contributions of recommended food environment policies to improve population nutrition: results from a Delphi study with international food policy experts. Public Health Nutr 2018:1–7.
  31. Taillie LS, Rivera JA, Popkin BM, Batis C. Do high vs. low purchasers respond differently to a nonessential energy-dense food tax? Two-year evaluation of Mexico’s 8% nonessential food tax. Prev Med 2017; 105S:S37–S42.
  32. European Commission. Survey on members states implementation of the EU salt reduction framework. Directorate-General Health and Consumers. Available from: http://ec.europa.eu/health/nutrition_physical_activity/docs/salt_report1_en.pdf 2012.
  33. Nghiem N, Blakely T, Cobiac LJ, Pearson AL, Wilson N. Health and economic impacts of eight different dietary salt reduction interventions. PLoS One 2015; 10:e0123915.
  34. Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis. Ann Int Med 2010; 152:481–7, W170-3.
  35. Cobiac LJ, Tam K, Veerman L, Blakely T. Taxes and Subsidies for Improving Diet and Population Health in Australia: A Cost-Effectiveness Modelling Study. PLoS Med 2017; 14:e1002232.
  36. He F, Campbell N, Ma Y, MacGregor G, Cogswell M, Cook N. Errors in estimating usual sodium intake by the Kawasaki formula alter its relationship with mortality - Implications for public health. Int J Epidemiol 2018; (E-publication 22 June).
  37. Nghiem N, Blakely T, Cobiac LJ, Cleghorn CL, Wilson N. The health gains and cost savings of dietary salt reduction interventions, with equity and age distributional aspects. BMC Public Health 2016; 16:423.
  38. Wilson N, Nghiem N, Eyles H, Mhurchu CN, Shields E, Cobiac LJ, Cleghorn CL, Blakely T. Modeling health gains and cost savings for ten dietary salt reduction targets. Nutr J 2016; 15:44.
  39. BODE3 Programme. League table. http://nzcms-ct-data-explorer.shinyapps.io/trimleaguetable2/
  40. GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet; 2018; (published online Aug 23.) http://dx.doi.org/10.1016/S0140-6736(18)31310-2
  41. Wood A, Kaptoge S, Butterworth A, et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599912 current drinkers in 83 prospective studies. Lancet 2018; 391:1513–23.
  42. Institute of Health Metrics and Evaluation. Country profiles: New Zealand. (Accessed 27 June 2018). http://www.healthdata.org/results/country-profiles
  43. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 2009; 104:179–90.
  44. Wagenaar AC, Tobler AL, Komro KA. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. Am J Public Health 2010; 100:2270–8.
  45. Cil G. Effects of posted point-of-sale warnings on alcohol consumption during pregnancy and on birth outcomes. J Health Econ 2017; 53:131–55.
  46. Gu J, Mohit B, Muennig PA. The cost-effectiveness of bike lanes in New York City. Inj Prev 2017; 23:239–43.
  47. Gotschi T. Costs and benefits of bicycling investments in Portland, Oregon. J Phys Act Health 2011;8 Suppl 1:S49–58.
  48. Hirsch JA, Meyer KA, Peterson M, Zhang L, Rodriguez DA, Gordon-Larsen P. Municipal investment in off-road trails and changes in bicycle commuting in Minneapolis, Minnesota over 10 years: a longitudinal repeated cross-sectional study. Int J Behav Nutr Phys Act 2017; 14:21.


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