Statin treatment for CHD

Current situation

  • In the UK it is estimated that cholesterol levels greater than 5.2mmol/l are a contributory factor in 46 per cent of CHD deaths.
  • There is overwhelming evidence that statins are highly beneficial for both primary and secondary prevention of CHD.
  • There is currently a debate about cholesterol targets and what they should be.
  • Statin prescribing has increased by 30 per cent every year since the publication of the NSF for CHD.

What is the evidence?

  • The ASTEROID study involved patients taking high-dose (40mg) rosuvastatin and then monitoring their cholesterol levels and also their atherosclerosis within the coro- nary arteries by intravascular ultrasound (JAMA 2006; 295: 1,556–65). Results were impressive — significant regression of atherosclerosis was demonstrated.
  • Data from the CARDS study showed that atorvastatin treatment resulted in an impressive 38 per cent relative risk reduction of first major cardiovascular event in patients with type-2 diabetes aged 65–75 years (Diabetes Care 2006; 29: 2,378–84).
  • One comparative analysis has shown that there is no significant differences in the effectiveness of the three most commonly used statins (Am Heart J 2006; 151: 273–81).
  • A meta-analysis has demonstrated that higher doses of statins work better in patients with CHD, largely by preventing more non-fatal cardiovascular events such as heart attacks and strokes (J Am Coll Cardiol 2006; 48: 438).
    The authors calculated that, compared with a standard dose, high-dose statins would prevent an extra 35,000 cardiovascular events for every million people treated each year (NNT 29).
  • GPs are still underprescribing to elderly patients (J Public Health 2007; 29: 40–7).
  • The DISCOVERY-UK study has shown that rosuvastatin is more effective than atorvastatin or simvastatin for lowering LDL-cholesterol and achieving lipid targets (Br J Cardiol 2006; 13: 72–6).

Implications for practice

  • In many cases statins alone will not be enough to meet the targets. It is likely that a combination of drugs will be used more in the future.
  • An editorial has recently cast serious doubt on the current policy on use of statins, because evidence to support their use in women and men older than 69 is still questionable (Lancet 2007; 369: 168–9).

Available guidelines

  • The Joint British Societies’ guidelines (JBS2) recommended that statins are prescribed to a wider group of patients and have introduced tougher cholesterol targets (Heart 2005; 91 (suppl V): v1-v52).
    It is suspected that the new NICE lipid guidance, due by the end of the year, will stick to 5mmol/l for total cholesterol.

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