Correlation of non-high-density lipoprotein cholesterol with apolipoprotein B: effect of 5 hydroxymethylglutaryl coenzyme A reductase inhibitors on non-high-density lipoprotein cholesterol levels

Current and future aims of lipid-lowering therapy: changing paradigms and lessons from the Heart Protection Study on standards of efficacy and safety

Lipid-lowering guidelines continue to evolve toward the use of (1) global risk assessment, (2) lipid measures other than or in addition to low-density lipoprotein (LDL) cholesterol in assessment of risk and treatment benefit, and (3) recommendations for more aggressive lipid lowering. Findings in the Heart Protection Study (HPS) indicate that high-risk patients benefit from statin therapy initiated at a dose that provides aggressive lowering of LDL cholesterol. Statin treatment in this trial provided consistent benefits in reducing major vascular events among a wide variety of high-risk patients, including those beginning treatment with LDL cholesterol levels <100 mg/dL. The HPS findings therefore suggest that the optimal LDL cholesterol level is well below current target levels. In addition, they provide reassurance that aggressive statin therapy is safe. Frequently, current targets for LDL cholesterol are not achieved in clinical practice, particularly among those patients who have coronary artery disease or are at high risk of disease. More intensive lipid lowering than that currently practiced is necessary to achieve current goals and to provide the aggressive reduction of LDL cholesterol shown to improve outcomes in clinical trials. New statins, such as rosuvastatin, offer the prospect of improved lipid-lowering therapy.

Role of lipid and lipoprotein profiles in risk assessment and therapy

Although low-density lipoprotein cholesterol (LDL-C) remains the primary target for coronary heart disease (CHD) prevention in the latest guidelines of the National Cholesterol Education Program, many individuals who have CHD do not have substantially elevated LDL-C but have derangement of other lipid fractions, most commonly low levels of high-density lipoprotein cholesterol (HDL-C). In the guidelines, HDL-C is important in risk stratification in primary prevention, influencing the need for and intensity of treatment of LDL-C, and both HDL-C and triglyceride are defined as risk factors for the metabolic syndrome, a secondary target of therapy. Triglyceride level also determines in which individuals non-HDL-C should be a secondary target of therapy. Risk assessment that takes into account the entire lipid profile will identify more high-risk individuals than evaluating LDL-C alone. Some epidemiologic data suggest that instead of measuring the cholesterol in LDL or HDL, measuring their respective apolipoproteins, apolipoprotein (apo) B-100 and apo A-I, may improve CHD risk assessment, and in some observational and interventional studies, ratios of lipids and/or apolipoproteins have been better predictors of CHD risk than levels of any one lipid fraction. Trials of lipid-modifying therapy also suggest that apolipoproteins and ratios may provide improved targets for therapy beyond LDL-C, but optimal values have not been established. Because lipid-modifying therapy affects multiple components of the lipid profile, the effect on all lipid parameters should be considered when selecting the most appropriate agent. Therapies with beneficial effects across the lipid profile would be expected to improve CHD risk reduction.

Non-high-density lipoprotein cholesterol and cardiovascular disease

PURPOSE OF REVIEW

Non-HDL cholesterol was designated a secondary target of therapy in the recent Adult Treatment Panel III report. This paper reviews correlates of non-HDL cholesterol levels and summarizes the available data on non-HDL cholesterol as a predictor of cardiovascular events as well as data linking treatment-induced changes in non-HDL cholesterol to cardiovascular outcomes.

RECENT FINDINGS

Non-HDL cholesterol levels in the population vary by age, sex, and race and are closely linked to measures of adiposity, especially visceral adiposity. Several reports in populations with and without cardiovascular disease have recently been published that document the prognostic utility of non-HDL cholesterol levels. Preliminary data are also available to suggest that pharmacologically induced changes in non-HDL cholesterol levels relate to prognosis.

SUMMARY

Non-HDL cholesterol is a potent predictor of cardiovascular risk among a broad range of individuals with and without cardiovascular disease and is prognostic over a wide range of follow-up periods. The impact of pharmacologically induced changes in non-HDL cholesterol on cardiovascular outcomes is less clear and requires further study.

Sex and time differences in the associations of non-high-density lipoprotein cholesterol versus other lipid and lipoprotein factors in the prediction of cardiovascular death (The Rancho Bernardo Study)

Non-high-density lipoprotein (HDL) cholesterol (total cholesterol [TC] minus HDL cholesterol) has been suggested as the preferred lipid fraction to predict cardiovascular disease. We compared the ability of lipids, lipoproteins, the ratio of total to HDL cholesterol (TC/HDL), and non-HDL cholesterol to predict fatal coronary heart disease (CHD) and cardiovascular disease in 1,386 women and 1,094 men (mean age 69 years). After 10 years, there were more deaths in men (n = 310) than women (n = 268), but the proportions of deaths attributed to CHD (23% and 25%, respectively) and cardiovascular disease (48% and 47%) were similar. In men, age-adjusted values for non-HDL cholesterol, TC/HDL ratio, and triglycerides each predicted a significantly increased risk of CHD and cardiovascular disease; none of these associations was independent of pack-years of smoking, systolic blood pressure, fasting plasma glucose, body mass index, and physical activity. In women, age-adjusted non-HDL cholesterol levels did not predict CHD or cardiovascular disease events before or after adjusting for these covariates and for estrogen replacement therapy. In women, only the ratio of TC to HDL cholesterol predicted CHD and cardiovascular disease deaths independent of estrogen use and other risk factors. Observed associations were sensitive to time, being evident in women at 3 and 5 years, and lost thereafter, but not apparent before 10 years in men. Thus, non-HDL cholesterol is not superior to individual lipids, lipoproteins, or their ratios in the prediction of cardiovascular death in older adults.

The combination of nebivolol plus pravastatin is associated with a more beneficial metabolic profile compared to that of atenolol plus pravastatin in hypertensive patients with dyslipidemia: a pilot study

Nebivolol, a selective beta1-lipophilic blocker, achieves blood pressure control by modulating nitric oxide release in addition to b-blockade. This dual mechanism of action could result in minimum interference with lipid metabolism compared to atenolol, a classic beta1-selective blocker. Hypertensive patients commonly exhibit lipid abnormalities and frequently require statins in combination with the anti-hypertensive therapy. We conducted this trial in order to clarify the effect on the metabolic profile of beta-blocker therapy with atenolol or nebivolol alone, or in conjunction with pravastatin. Thirty hypertensive hyperlipidemic men and women (total cholesterol >240 mg/dL [6.2 mmol/L], low-density lipoprotein cholesterol >190 mg/dL [4.9 mmol/L], triglycerides <500 mg/dL [5.6 mmol/L]) were separated in two groups. One group consisted of 15 subjects on atenolol therapy (50 mg daily), and the other group included 15 subjects on nebivolol therapy (5 mg daily). After 12 weeks of beta-blocker therapy, pravastatin (40 mg daily) was added in both groups for another 12 weeks. Atenolol significantly increased triglyceride levels by 19% (P=.05), while nebivolol showed a trend to increase high-density lipoprotein cholesterol by 8% (NS) and to decrease triglyceride levels by 5% (NS). Atenolol significantly increased lipoprotein(a) by 30% (P=.028). Fibrinogen levels were equally and not significantly decreased in both groups by 9% and 7%, respectively. Furthermore, atenolol and nebivolol decreased serum high-sensitivity C-reactive protein levels by 14% (P=.05) and 15% (P=.05), respectively. On the other hand, both atenolol and nebivolol showed a trend to increase homocysteine levels (NS) by 13% and 11%, respectively. Although uric acid levels remained the same, atenolol significantly increased the fractional excretion of uric acid by 33% (P=.03). Following nebivolol administration, glucose levels remained the same, while insulin levels were reduced by 10% and the HOMA index (fasting glucose levels multiplied by fasting insulin levels and divided by 22.5) was reduced by 20% (P=.05). There were no significant differences between the two patient groups in the measured parameters after the administration of beta-blockers, except for triglycerides (P<.05) and the HOMA index (P=.05). The addition of pravastatin to all patients (n=30) decreased total cholesterol by 21% (P<.001), low-density lipoprotein cholesterol by 28% (P<.001), apolipoprotein-B by 22% (P<.001), apolipoprotein-E by 15% (P=.014) and lipoprotein(a) levels by 12% (P=.023). Moreover, homocysteine levels and C-reactive protein were reduced by 17% (P=.05) and 43% (P=.05), respectively. We conclude that nebivolol seems to be a more appropriate therapy in hypertensive patients with hyperlipidemia and carbohydrate intolerance. Finally, the addition of pravastatin could further correct the well-established predictors of cardiovascular events.

Concordance/discordance between plasma apolipoprotein B levels and the cholesterol indexes of atherosclerotic risk

The objective of the present study was to examine concordance/discordance among 4 atherogenic indexes of cardiovascular risk: plasma total cholesterol, low-density lipoprotein (LDL) cholesterol, non-high-density lipoprotein (non-HDL) cholesterol, and apolipoprotein B-100 (apoB). Analyses were conducted in a cohort of 2,103 men without coronary artery disease (CAD) at the onset of the Quebec Cardiovascular Study. Although there were strong and highly significant correlations among the 4 risk indexes (0.78 < r < 0.97), only 50% of all subjects had concordant apoB and LDL cholesterol levels (i.e., values that fell into the same quintile of the population distribution). Moreover, concordance/discordance was not the same throughout the range of both variables; it was greater at the extremes of their respective distributions (65%), but significantly less in the midpoints (<40%). ApoB appeared to be more concordant with non-HDL cholesterol than with LDL cholesterol, although >1/3 of all subjects had discordant levels. Kappa analysis confirmed that there was only fair agreement between apoB and total or LDL cholesterol (0.38 and 0.36, respectively) and only moderate agreement between non-HDL cholesterol and apoB (0.47). Finally, a significant proportion of subjects (528 of 2,103) who had disproportionately higher apoB levels than would have been predicted based on their LDL cholesterol concentrations was more obese and manifested several features of the metabolic syndrome. They also had a significantly increased cardiovascular risk. In summary, plasma apoB and the various cholesterol indexes are complementary rather than competitive indexes of atherosclerotic risk and provide further evidence as to why measurement of apoB should be part of a standard lipoprotein assessment of CAD risk.

Benefits of aggressive drug therapy

Significant advances have been made in both the development and implementation of drug therapy in the primary and secondary prevention of cardiovascular disease. Defining "aggressive" drug therapy mandates consideration of the target population, timing of initiation, time of administration, and, often, dose titration to achieve a desired effect on relevant "biomarkers" such as low-density lipoprotein levels. This review focuses on 2 groups of drug therapies now proven effective in prevention, namely the statins and antiplatelet drugs (aspirin, clopidogrel). Angiotensin-converting enzyme inhibitor(s), angiotensin receptor blockers, and beta blockers are also proven of great value but are only noted in the table.

New features of the National Cholesterol Education Program Adult Treatment Panel III lipid-lowering guidelines

The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines for lipid-lowering therapy to reduce coronary heart disease (CHD) risk contain a number of features that distinguish them from the previous ATP guidelines. These new features include modifications in lipid/lipoprotein levels considered optimal, abnormal, or reflective of risk; increased focus on primary prevention through use of Framingham risk scoring to define risk in persons with multiple lipid/nonlipid risk factors; and increased focus on the association of the metabolic syndrome with CHD risk. The introduction of the category of CHD risk equivalents-including persons with atherosclerotic disease, diabetes, or 10-year CHD risk > 20% based on Framingham scoring-results in an increase over previous guidelines in the proportion of patients categorized as being at high risk and therefore eligible for more intensive low-density lipoprotein cholesterol (LDL-C)-lowering therapy. Use of the new secondary therapeutic target of non-high-density lipoprotein cholesterol should improve management of lipid risk factors in patients who have elevated triglyceride levels after LDL-C goals have been met. These new features of the NCEP ATP III guidelines should improve identification and treatment of patients with dyslipidemias associated with CHD risk.

An economic analysis of the Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS)

INTRODUCTION

The objective of the Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS) was to compare the efficacy and safety of the five 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors in a randomised, controlled, yet large-scale study. ACCESS also produced data that permitted comparative analysis of the cost to achieve National Cholesterol Education Panel (NCEP) II low density lipoprotein-cholesterol (LDL-C) targets.

STUDY DESIGN

A 54-week, multicentre, open-label, randomised, parallel-arm, active-control study in men and women with or without documented coronary heart disease or peripheral vascular disease. Data included medication use, clinic visits, adverse events, LDL-C and other laboratory measures. Analyses of resource use and cost are reported from a third-party payer perspective.

METHODS

Patients were randomly assigned to receive one of the following treatments: atorvastatin (10-80 mg/day); fluvastatin (20-40 mg/day, or 40 mg twice daily); lovastatin (20-40 mg/day, or 40 mg twice daily); pravastatin (10-40 mg/day); or simvastatin (10-40 mg/day). Patients were started at the lowest available dose and titrated to higher doses at 6-week intervals until they achieved the NCEP II LDL-C target or reached the highest available dose of medication.

PATIENTS

A total of 153 centres enrolled 3887 patients: atorvastatin (n = 1944); fluvastatin (n = 493); lovastatin (n = 494); pravastatin (n = 478); and simvastatin (n = 478). Inclusion criteria included LDL-C >or= 30 mg/dL higher than NCEP II LDL-C target (stratified by risk factors), fasting triglyceride values < 400 mg/dL, and a confirmed negative serum pregnancy test. Known hypersensitivity to statins, use of prohibited medications, uncontrolled diabetes, acute liver disease and age > 80 years or < 18 years were among the exclusion criteria.

RESULTS

Mean total treatment costs to reach LDL-C targets for patients receiving atorvastatin (US dollars 683.37 in 2001) were significantly less than mean total treatment costs for patients receiving fluvastatin (difference = US dollars 211.35, p < 0.01), lovastatin (US dollars 607.96, p < 0.01), pravastatin (US dollars 424.60, p < 0.01) and simvastatin (US dollars 95.74, p < 0.01). Results were robust to sensitivity analyses using alternative definitions of the patient population (randomised, intent-to-treat, completers) and cost measures (50th percentile charges, 95th percentile charges, Medicare prices).

CONCLUSIONS

Compared with the other statins studied, atorvastatin was associated with the lowest resource use and costs when used to treat patients to their NCEP II LDL-C targets. Atorvastatin was also associated with the highest percentage of patients achieving their desired clinical outcomes. Therefore, in cost-effectiveness terms, it dominated the four other statins.

Comparative effects of rosuvastatin and atorvastatin across their dose ranges in patients with hypercholesterolemia and without active arterial disease

The lipid-lowering effects of rosuvastatin and atorvastatin were determined across their dose ranges in a 6-week, randomized, double-blind trial. Three hundred seventy-four hypercholesterolemic patients with fasting low-density lipoprotein (LDL) cholesterol > or =160 but <250 mg/dl (> or =4.14 but <6.47 mmol/L) and fasting triglycerides <400 mg/dl (<4.52 mmol/L) and without active arterial disease within 3 months of entry received once-daily rosuvastatin (5, 10, 20, 40, or 80 mg [n = 209]) or atorvastatin (10, 20, 40, or 80 mg [n = 165]). The percentage decrease in plasma LDL cholesterol versus dose was log-linear for each drug, ranging from -46.6% to -61.9% for rosuvastatin 10 and 80 mg, compared with -38.2% to -53.5% for atorvastatin 10 and 80 mg. The dose curve for rosuvastatin yielded an 8.4% greater decrease in LDL cholesterol compared with atorvastatin at any given dose (p <0.001). Similarly greater decreases were observed for rosuvastatin across the dose range in total cholesterol (-4.9%), non-high-density lipoprotein (non-HDL) cholesterol (-7.0%), apolipoprotein B (-6.3%), and related ratios versus atorvastatin (all p <0.001). Because dose responses for HDL cholesterol, triglycerides, and apolipoprotein A-I were non-log-linear and nonparallel between the 2 drugs, percentage changes from baseline were compared at each dose. Significantly greater increases for rosuvastatin compared with atorvastatin were observed for HDL cholesterol at 40 and 80 mg, and for apolipoprotein A-I at 80 mg. Significantly greater triglyceride decreases were seen at 80 mg with atorvastatin over rosuvastatin. Both rosuvastatin and atorvastatin were well tolerated over 6 weeks.

Combination therapy for combined dyslipidemia

Patients with combined dyslipidemia are at high risk for coronary artery disease and often require combination drug therapy to achieve lipid levels recommended by the US National Cholesterol Education Program's third Adult Treatment Panel (ATP III). In addition to recommendations for low-density lipoprotein (LDL) cholesterol and triglyceride levels, ATP III established non-high-density lipoprotein (HDL) cholesterol goals for individuals with triglycerides >or=2.26 mmol/L (>or=200 mg/dL). It also introduced certain criteria for the diagnosis of the metabolic syndrome, a clustering of risk factors (abdominal obesity, elevated triglycerides, low HDL cholesterol, elevated blood pressure, impaired fasting glucose) that increases cardiovascular risk and is common in patients with combined dyslipidemia. Statin monotherapy has been shown to benefit these patients, and additional benefit may be obtained by combination therapy that provides greater reductions in both LDL cholesterol and triglycerides as well as greater increases in HDL cholesterol. However, combining a statin with either niacin or a fibrate may increase the risk for myopathy and therefore requires careful monitoring and evaluation of the risk-benefit ratio for each patient. Moreover, combination therapy may be associated with increased drug costs and decreased patient compliance. Recently developed agents that may improve the effectiveness of combination therapy include ezetimibe-a cholesterol absorption inhibitor-and a formulation that combines extended-release niacin and lovastatin in a single pill. Clinical trials are needed to determine the optimal treatment in patients with combined dyslipidemia.

Combination therapy for elevated low-density lipoprotein cholesterol: the key to coronary artery disease risk reduction

Lowering elevated low-density lipoprotein (LDL) cholesterol is a key management principle in reducing the risk of coronary artery disease (CAD). An aggressive approach to CAD risk reduction requires multiple therapeutic strategies, as no single approach is likely to succeed independently. The use of combination therapy for elevated LDL cholesterol is effective for CAD risk reduction. In fact, the majority of patients with CAD are unlikely to achieve their treatment goals with monotherapy. This article reviews the use of combination therapy for the management of elevated LDL cholesterol, highlighting important therapy considerations.

Approach to lipoprotein management in 2001 National Cholesterol Guidelines

In 2001 the National Cholesterol Education Program (NCEP) released its Adult Treatment Panel (ATP) III report. This was an evidence-based report that upgraded cholesterol management guidelines. The update was made possible by a series of large, cholesterol-lowering clinical trials. These trials demonstrated strongly the efficacy and safety of cholesterol reduction in both primary and secondary prevention of coronary heart disease (CHD). The major recommendations of the report were several. Low-density lipoprotein (LDL) cholesterol continued to be identified as the major target of cholesterol-lowering therapy. However, more emphasis was given to HDL cholesterol and triglycerides as important targets for management. The concept of CHD risk equivalents was introduced. A CHD risk equivalent represents an absolute risk for future CHD events equal to that in persons with established CHD. Diabetes was identified as a CHD risk equivalent, requiring more intensive LDL-lowering therapy. Finally, the report placed more emphasis on the metabolic syndrome as a major, multiplex risk factor requiring increased clinical attention.

Distribution and correlates of non-high-density lipoprotein cholesterol in children: the Bogalusa Heart Study

OBJECTIVE

Serum non-high-density lipoprotein (HDL) cholesterol (total cholesterol minus HDL cholesterol) is considered a better screening tool than low-density lipoprotein (LDL) cholesterol for the assessment of coronary artery disease (CAD) risk in adults because it includes all classes of atherogenic lipoproteins. Although population frequency distribution and clinically useful cutpoints for this variable in adults have been reported recently, such information is lacking in children. Therefore, this study sought to provide population-based data on the distribution and correlates of non-HDL cholesterol in biracial (black-white) children.

METHODS

The study sample consisted of 2843 5- to 17-year-olds (57% white, 50% female) who participated in a cross-sectional screening of cardiovascular risk factors as part of the Bogalusa Heart Study.

RESULTS

Non-HDL cholesterol levels were similar in black and white children, and higher in girls than in boys, especially among the younger (5-11 years) age group. Age was inversely related to both non-HDL cholesterol and LDL cholesterol. Body fatness as measured by body mass index and waist circumference was positively associated with non-HDL cholesterol. The magnitude of correlation with triglycerides was relatively higher for non-HDL cholesterol versus LDL cholesterol. Non-HDL cholesterol showed an inverse relation to HDL cholesterol. In a multivariate analysis, body mass index, age, gender, waist circumference, and cigarette smoking accounted for 7.7% of the variance in non-HDL cholesterol. Non-HDL cholesterol levels equivalent to currently recommended LDL cutpoints (110, 130, 160, and 190 mg/dL) for CAD risk assessment were 123, 144, 176, and 207 mg/dL.

CONCLUSION

Population-based data on non-HDL cholesterol are now available for children, which may help improve the CAD risk assessment and intervention.

Management of dyslipidemia in the primary prevention of coronary heart disease

Coronary heart disease is a leading cause of death in industrialized nations. Hyperlipidemia with elevated serum total cholesterol, LDL cholesterol, and triglycerides is a known major cardiovascular risk factor. HDL cholesterol is considered to be protective, so low HDL cholesterol is being recognized as an independent cardiovascular risk factor that contributes to the development of atherosclerosis and related adverse cardiovascular events. The recognition of insulin resistance and metabolic syndrome is a step further in understanding these risk factors. Attempts at reducing serum cholesterol with different strategies in the past have met with limited success until the development of statins. The advent of statins has revolutionized the management of hyperlipidemia. The post-statins era has seen major clinical trials demonstrating the benefit of cholesterol reduction in the setting of both primary and secondary prevention. In general, there appears to be a 25% to 40% relative risk reduction in major adverse cardiovascular events such as death, myocardial infarction, and stroke. The recent megatrials further suggest that aggressive management of cholesterol in patients with high cardiovascular risk may be beneficial. Though the concept of the-lower-the-better may be looming, the question of "How low is good enough?" remains controversial. The results of recent megatrials such as the Heart Protection Study go a step further than the NCEP guidelines and suggest that statin therapy may benefit patients at high risk of cardiovascular disease regardless of their baseline values. We summarize the results of the available large clinical trials in our understanding of the management of dyslipidemia in a setting of primary prevention.

Perspectives: The significance of measuring non-HDL-cholesterol

The third Adult Treatment Panel of the National Cholesterol Education Program has recently issued revised guidelines for the treatment of cholesterol in adults. Increased attention to the metabolic syndrome and diabetes, including the inaccuracy of the low-density lipoprotein cholesterol (LDL-C) measurement in these patients because of elevated triglycerides is highlighted. To overcome the inaccuracy of the Friedewald equation in calculating LDL-C when the triglycerides are elevated, measuring non-high-density lipoprotein (non-HDL-C) may provide a better means to follow these patients toward their treatment goals. Recently, non-HDL-C was shown to be a better predictor of cardiovascular death than LDL-C, even in patients with triglyceride levels below 200 mg/dL. The authors review the basis for using non-HDL-C as a treatment target for cholesterol, in comparison with other lipoproteins.

New cholesterol guidelines, new treatment challenges

Coronary heart disease (CHD) is the largest single killer of Americans. Epidemiologic trials have indicted low-density lipoprotein cholesterol (LDL) as directly correlating with CHD events, and clinical trials confirmed that lipid-lowering therapy decreases the risk of CHD events. The literature also indicates that only about 18% of these patients are treated to their goal LDL levels. New guidelines from the National Cholesterol Education Program extend the LDL-lowering recommendations, add a new non-high-density lipoprotein cholesterol (non-HDL) goal for patients with hypertriglyceridemia, and increase the number of drug-eligible patients from about 15 to 36 million. Most of those who are eligible for lipid-altering drug therapy have the highest CHD risk and require the most aggressive treatment to achieve goals. This presents a challenge to clinicians: how best to achieve LDL and non-HDL goals. Statins are the most effective agents for lowering LDL and one of the most effective for lowering non-HDL. This efficacy and the ability to reduce CHD risk were well documented in a number of randomized clinical trials. When statin monotherapy fails to achieve goals, a bile acid resin, niacin, or both may be added to lower LDL further, or a fibrate, niacin, or fish oils may be added to lower non-HDL further. Drugs are under development that may enhance our ability to reach LDL and non-HDL goals. Included are a group of so-called super statins, rosuvastatin and pitavastatin; agents that interfere with cholesterol or bile acid transport in the gut, such as ezetimibe; and dual peroxisome proliferator-activated receptor agonists that have both fibrate and thiazolidinedione-like effects.

Treatment with atorvastatin to the National Cholesterol Educational Program goal versus 'usual' care in secondary coronary heart disease prevention. The GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study

BACKGROUND

Atorvastatin is very effective in reducing plasma low-density lipoprotein cholesterol (LDL-C) levels. However, there is no long-term survival study that evaluated this statin.

PATIENTS-METHODS

To assess the effect of atorvastatin on morbidity and mortality (total and coronary) of patients with established coronary heart disease (CHD), 1600 consecutive patients were randomised either to atorvastatin or to 'usual' medical care. The dose of atorvastatin was titrated from 10 to 80 mg/day, in order to reach the National Cholesterol Education Program (NCEP) goal of LDL-C <100 mg/dl (2.6 mmol/l). All patients were followed up for a mean period of 3 years.

MAIN OUTCOME MEASURES

Primary endpoints of the study were defined as death, non-fatal myocardial infarction, unstable angina, congestive heart failure, revascularisation (coronary morbidity) and stroke. Secondary endpoints were the safety and efficacy of the hypolipidaemic drugs as well as the cost-effectiveness of atorvastatin.

RESULTS

The mean dosage of atorvastatin was 24 mg/day. This statin reduced total chlesterol by 36%, LDL-C by 46%, triglycerides by 31%, and non-high-density lipoprotein cholesterol (non-HDL-C) by 44%, while it increased HDL-C by 7%; all these changes were significant. The NCEP LDL-C and non-HDL-C treatment goals were reached by 95% (n = 759) and 97% (n = 776), respectively, of patients on atorvastatin. Only 14% of the 'usual' care patients received any hypolipidaemic drugs throughout the study and 3% of them reached the NCEP LDL-C treatment goal. The cost per quaility-adjusted life-year gained with atorvastatin was estimated at $US 8350. During this study 196 (24.5%) CHD patients on 'usual' care had a CHD recurrent event or died vs. 96 (12%) CHD patients on atorvastatin; risk ratio (RR) 0.49, confidence interval (CI) 0.27-0.73, p < 0.0001. In detail, atorvastatin reduced, in comparison to 'usual' care, total mortality (RR 0.57, CI 0.39-0.78, p = 0.0021), coronary mortality (RR 0.53, CI 0.29-0.74, p = 0.0017), coronary morbidity (RR 0.46, CI 0.25-0.71, p < 0.0001), and stroke (RR 0.53, CI 0.30-0.82, p = 0.034). All subgroups of patients (women, those with diabetes mellitus, arterial hypertension, age 60 to 75 years, congestive heart failure, recent unstable angina or prior revascularisation) benefited from treatment with atorvastatin. Withdrawal of patients because of side-effects from the atorvastatin group was low (0.75%) and similar to that of the 'usual' care group (0.4%).

CONCLUSIONS

Long-term treatment of CHD patients with atorvastatin to achieve NCEP lipid targets significantly reduces total and coronary mortality, coronary morbidity and stroke, in comparison to patients receiving 'usual' medical care. Treatment with atorvastatin is well tolerated and cost-effective.