Article, see p 1087

In this issue of Circulation, Heller et al¹ report results of a simulation model suggesting that the American Heart Association/American College of Cardiology (AHA/ACC) primary prevention lipid treatment guidelines treat many more people with a statin but also save many more lives compared with ATP III. These findings are consistent with previous reports,^2,3 but their results further suggest that starting a statin at 40 years of age in everyone regardless of cardiovascular disease (CVD) risk would extend statin treatment to >28 million more Americans but would further and substantially improve the public’s health, but only if the disutility associated with pill burden is quite low.

If starting a statin in all adults at 40 years of age would really save hundreds of thousands of quality-adjusted life years (QALYs), implementing such a policy would seem to be a public health priority. However, this perspective has several problems. Principally, taking a statin is an individual not a public health decision, such as interventions to improve air quality or a decision with externalities, such as treating contagious diseases. For an individual decision without externalities, an individual’s chance and magnitude of net benefit (absolute risk reduction minus absolute risk increase plus/minus uncertainties) is the only meaningful consideration.⁴ This may sound heretical, especially coming from a professor of public health, but the ethical and legal standards are clear. When counseling an individual patient about treatment, the most relevant question is almost always, “What is the magnitude of and uncertainty bounds for estimated net benefit for the considered treatment?” Heller et al¹ present a relevant estimate in this regard. If their base-case estimates are correct, adoption of the treat at 40 years of age policy, compared with AHA/ACC guidelines, would average 1 additional QALY gained …

文章，请参见第1087页

在这一期《循环》中，Heller等[ ^1]报告了一个模拟模型的结果，表明美国心脏协会/美国心脏病学会（AHA / ACC）一级预防脂质治疗指南用他汀类药物治疗更多人，但也挽救了更多生命与ATP III相比。这些发现与先前的报道一致，^2，3，但他们的研究结果进一步表明，起始于40岁在大家他汀类药物，无论心血管疾病（CVD）的风险会延长他汀类药物治疗> 2800万层以上的美国人，但将进一步且基本改善公众健康，但前提是与药丸负担相关的无用功很低。

如果在所有40岁的成年人中开始使用他汀类药物确实可以挽救成千上万的质量调整生命年（QALYs），那么实施这样的政策似乎将是公共卫生的重点。但是，这种观点有几个问题。原则上，服用他汀类药物不是个人的公共卫生决定，例如改善空气质量的干预措施，还是具有外部性的决定，例如治疗传染性疾病。对于没有外部性的个人决策，唯一有意义的考虑因素是个人的净收益机会和大小（绝对风险减少减去绝对风险增加加上/减去不确定性）。⁴这听起来可能是异端，尤其是来自公共卫生教授，但是道德和法律标准很明确。在咨询患者有关治疗的咨询时，最相关的问题几乎总是：“考虑的治疗的估计净收益的大小和不确定性范围是多少？” Heller等[ ^1]在这方面提出了相关的估计。如果他们的基本情况估计是正确的，那么与AHA / ACC指南相比，采用40岁年龄段治疗的政策将平均增加1个QALY…