Utility of statin therapy using high-sensitivity C-reactive protein as an indicator of coronary heart disease risk

Rosuvastatin, inflammation, C-reactive protein, JUPITER, and primary prevention of cardiovascular disease--a perspective

The major public health concern worldwide is coronary heart disease, with dyslipidemia as a major risk factor. Statin drugs are recommended by several guidelines for both primary and secondary prevention. Rosuvastatin has been widely accepted because of its efficacy, potency, and superior safety profile. Inflammation is involved in all phases of atherosclerosis, with the process beginning in early youth and advancing relentlessly for decades throughout life. C-reactive protein (CRP) is a well-studied, nonspecific marker of inflammation which may reflect general health risk. Considerable evidence suggests CRP is an independent predictor of future cardiovascular events, but direct involvement in atherosclerosis remains controversial. Rosuvastatin is a synthetic, hydrophilic statin with unique stereochemistry. A large proportion of patients achieve evidence-based lipid targets while using the drug, and it slows progression and induces regression of atherosclerotic coronary lesions. Rosuvastatin lowers CRP levels significantly. The Justification for Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial was designed after the observation that when both low density lipoprotein and CRP were reduced, patients fared better than when only LDL was lowered. Advocates and critics alike acknowledge that the benefits of rosuvastatin in JUPITER were real. After a review, the US Food and Drug Administration extended the indications for rosuvastatin to include asymptomatic JUPITER-eligible individuals with one additional risk factor. The American Heart Association and Centers of Disease Control and Prevention had previously recognized the use of CRP in persons with "intermediate risk" as defined by global risk scores. The Canadian Cardiovascular Society guidelines went further and recommended use of statins in persons with low LDL and high CRP levels at intermediate risk. The JUPITER study focused attention on ostensibly healthy individuals with "normal" lipid profiles and high CRP values who benefited from statin therapy. The backdrop to JUPITER during this period was an increasing awareness of a rising cardiovascular risk burden and imperfect methods of risk evaluation, so that a significant number of individuals were being denied beneficial therapies. Other concerns have been a high level of residual risk in those who are treated, poor patient adherence, a need to follow guidelines more closely, a dual global epidemic of obesity and diabetes, and a progressively deteriorating level of physical activity in the population. Calls for new and more effective means of reducing risk for coronary heart disease are intensifying. In view of compelling evidence supporting earlier and aggressive therapy in people with high risk burdens, JUPITER simply offers another choice for stratification and earlier risk reduction in primary prevention patients. When indicated, and in individuals unwilling or unable to change their diet and lifestyles sufficiently, the benefits of statins greatly exceed the risks. Two side effects of interest are myotoxicity and an increase in the incidence of diabetes.

Evaluation of Mangosteen juice blend on biomarkers of inflammation in obese subjects: a pilot, dose finding study

Background

The ability to reduce inflammation in overweight and obese individuals may be valuable in preventing the progression to metabolic syndrome with associated risks for heart disease and diabetes. The purpose of this study was to evaluate the effect of multiple dosages of a proprietary Mangosteen Juice blend on indicators of inflammation and antioxidant levels in obese patients with elevated C-reactive protein (CRP) levels.

Methods

The study was an 8 week randomized, double-blind, placebo-controlled study with a pre-study 2 week washout period. The study included four groups including placebo and three difference doses of the test product, XanGo Juice™: 3, 6 or 9 oz twice daily. The primary outcome measure of this study was high-sensitivity (HS)-CRP. Secondary outcome measures included other biochemical indicators of inflammation, anthropomorphic measures and a safety evaluation.

Results

One hundred twenty two (122) persons were screened for the study, 44 were randomized and 40 completed the study. HS-CRP measurements dropped after 8 weeks treatment compared to baseline in all 3 dose groups and increased in the placebo group. The changes from baseline were not significant but the comparison of change from baseline was significant for the 18 oz group when compared to placebo (p = 0.02). Other markers of inflammation (inflammatory cytokines) and a marker for lipid peroxidation (F2 isoprostane) did not show any significant differences when compared with placebo. There was a trend towards a decrease in BMI in the juice groups. There were no side effects reported in any of the groups and none of the laboratory or EKG safety assessments indicated clinically significant changes for any subject.

Conclusion

In this pilot, dose-finding study, a proprietary mangosteen juice blend (XanGo Juice™) reduced CRP levels (increased change from baseline) compared to placebo for those taking the highest dose of 18 oz per day. Further studies with a larger population are required to confirm and further define the benefits of this juice. The juice was administered safely.

Trial Registration

ISRCTN9300027

From Here to JUPITER

Background— Guidelines for statin use currently focus on patients with elevated low-density lipoprotein levels. Recent findings from the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), however, indicate that statin therapy to reduce cardiovascular risk is also effective among older persons with at-goal low-density lipoprotein but elevated high-sensitivity C-reactive protein levels. We estimate the size of and describe this new population for whom statin therapy may now be indicated based on JUPITER’s findings.

Methods and Results— Using data from the 1999 to 2004 National Health and Nutrition Examination Survey, we estimate that 57.9% of older adults (men ≥50 years and women ≥60 years), or 33 547 000 (95% CI, 32 217 000 to 34 877 000) Americans, are currently taking a statin (24.4%) or indicated for statin therapy (33.5%). In addition, we estimate that 19.2%, or 11 144 000 (95% CI, 10 053 000 to 12 235 000), may become newly eligible for statin therapy. This includes 8 071 000 (13.9%; 95% CI, 7 173 000 to 8 969 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein <130 mg/dL (ie, those meeting “strict” JUPITER criteria) and an additional 3 073 000 (5.3%; 95% CI, 2 404 000 to 3 743 000) with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein of 130 to 160 mg/dL for whom JUPITER’s findings might reasonably be extended. Thus, ≈80% of older persons may now have an indication for statin therapy. Compared with those who would continue to have no indication for statin therapy, the JUPITER group was more likely to be female, to be older, and to have obesity, hypertension, and the metabolic syndrome.

Conclusions— JUPITER’s findings have the potential to impact treatment recommendations for ≈20% of middle-aged to elderly adults, thus increasing the proportion of this segment of the population with an indication for statin therapy to nearly 80%.