Cholesterol Conundrum

Statins have time and again proven their worth in prevention of cardiovascular events.  To add to the evidence is the “Effect of two intensive statin regimens on progression of coronary disease” (SATURN) trial which looked at atorvastatin and rosuvastatin therapy in patients with at least 20% occlusion in one or more vessels.  

Patients who’s cholesterol reached less than 116mg/dL with either atorvastatin 40mg or rosuvastatin 20mg were again randomized 1:1 to maintain the dosage or to increase.  

There was a statistically significant reduction  in percent atheroma volume in patients taking rosuvastatin, but the clinical benefit remains unknown.

Treat the patient, not the number

“Treat the patient, not the numbers” is one of the many mantras of medicine, yet clinical decisions regarding lipid management are far from simplistic.

Undisputed, dyslipidemia is a major risk factor for cardiovascular events, and while statins continue to show benefit, there is a dearth of evidence supporting clinical benefit with other antilipid therapies.

The AIM-HIGH trial was stopped early due to lack of benefit seen in adding niacin to simvastatin in patients with low HDL and high triglycerides.  The 2008 ENHANCE trial failed to show clinical benefit to adding ezetimibe to simvastatin, although the SHARP trial published earlier this year showed that ezetimibe with simvastatin in patients with chronic kidney injury decreased stroke and re-vascularization compared with a non-study statin.  The ACCORD-lipid trial failed to show clinical benefit to adding fenofibrate to simvastatin.

What these trials all have in common is that they examine non-statin anti-lipid therapy in addition to a statin.  Currently there is a lack of evidence of the benefits of these therapies in patients whom are unable to tolerate a statin.  

Patients who are not at goal but tolerating a statin may receive more benefit being switched to a more potent statin than to add a medication.  Fibrates, niacin, and ezetimbe should still be recommended for patients unable to tolerate a statin.

References:

Nicholls SJ, Ballantyne CM, Barter PJ, Chapman MJ, Erbel RM, Libby P et al.  Effect of two intensive statin regimens on progression of cornoary disease.  The New England Journal of Medicine 2011;365:2078-87.

Boden WE, Probstfield JL, Anderson T, Chaitman BR, Koprowicz K, McBride R et al.  Niacin in patients with low HDL cholesterol levles receiving intensive statin therapy.  The New England Journal of Medicine 2011;365:2255-67.

Kastelein JJP, Akdim F, Stroes ESG, Zwinderman AH, Bots ML, Stalenhoef AFH et al.  Simvastatin with or without ezetimibe in familial hypercholesterolesmia.  The New England Journal of Medicine 2008;358:1431-43.

Baigent C, Landray MJ, Reith C, Emberson J, Wheeler DC, Tomson C et al.  The effects of lowering LDL cholesterol with simvastin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial  The Lancet 2011;377:2181-92.

Ginsberg HN, Elam MB, Lovato LC, Crouse JR, Leiter LA, Linz P et al.  Effects of combination lipid therapy in type 2 diabetes mellitus.  The New England Journal of Medicine 2010;362(17): 1563-74.