For those who want to do more reading on this issue, Medscape has a nice review (registration required) – NCEP Updates ATP III Guidelines With Evidence From Recent Statin Trials

One of my colleagues questioned the rapidity of the NCEP’s decision to lower the targets. He appropriately questions the data. Here is a summary of the data used to reach this new recommendation.

The five trials used to revise the recommendations are (a) the secondary prevention U.K. Heart Protection Study (HPS) study of adults aged 40 to 80 years showing a risk reduction of 13% for all cause mortality, 24% for major vascular events, 27% for coronary death rate, and 25% for coronary revascularization with 40 mg of simvastatin daily compared with placebo; (b) Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), a 3.2-year study of secondary prevention in the elderly aged 70 to 82 years showing LDL-cholesterol reduction of 34% with risk reduction of 19% for coronary events and 24% for coronary heart disease (CHD) mortality with 40 mg of pravastatin daily compared with placebo; (c) Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a study of older adults with hypertension and moderate hypercholesterolemia that showed similar six-year mortality and CHD events for the pravastatin and the placebo groups with significant protection only for the African-American subgroup; (d) Anglo-Scandinavian Cardiac Outcomes Trial Lipid-Lowering Arm (ASCOT-LLA) which was a primary prevention study prematurely terminated at 3.3 years because of a reduced risk of 36% for all CHD events, 21% for cardiovascular events, and 27% for stroke for atorvastatin compared with placebo; and (e.) Pravastatin and Atorvastatin Evaluation and Infection (PROVE IT), a two-year head-to-head comparison of atorvastatin, 80 mg, (intensive dose) with pravastatin, 40 mg, (standard dose) showing a 16% improvement of cardiovascular endpoint for atorvastatin compared with pravastatin with better lowering of LDL-cholesterol level (endpoint, 62 mg/dL compared with 95 mg/dL).

All five trials supported a log-linear relationship between LDL-cholesterol level and CHD risk but did not identify an LDL-cholesterol level below which no further risk reduction occurred. k has been shown between very low LDL-cholesterol levels and cerebral hemorrhage, a causal link with mortality and morbidity has not been established. Statin therapy is considered safe. This ATP III report updates the 2001 report.

Dr. Scott Grundy, the chair of the panel, comments:

“There is strong suggestive evidence that lower LDL cholesterol is better, but it has to be balanced against the cost and side effects of achieving very low levels, which often requires high doses of medication or combination therapy,” Dr. Grundy says. “The idea that you can use cholesterol-lowering drugs without lifestyle changes is incorrect. Lifestyle changes have enormous benefits beyond lowering LDL cholesterol, such as raising levels of good cholesterol, lowering triglycerides, improving diabetes, and reducing inflammation.“

So how do I operationalize these new recommendations. As I suggested yesterday, I would probably choose atorvastatin 80 mg for all patients needing secondary prevention. This drug is priced reasonably for the dose and effect (see yesterday’s rant).

Related posts:

1. Defining the proper guidelines – the case of cholesterol targets
2. Maybe lowering cholesterol does not matter
3. Lowering cholesterol
4. Modest lifestyle changes do not help cholesterol
5. Statins for diabetes

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