Gender and diet interactions with simvastatin treatment

Ethnicity based differences in statin use and hypercholesterolemia control among patients with premature coronary artery disease-results of I-PAD study

Background

Statins use is the most important treatment for high LDL cholesterol in patients with premature coronary artery disease (CAD). Previous reports have shown racial and gender differences in statin use in the general population, but this wasn't studied in premature CAD based on different ethnicities.

Methods and results

Our study includes 1917 men and women with confirmed diagnosis of premature CAD. Logistic regression model was used to evaluate the high LDL cholesterol control in the groups and the OR with 95% confidence interval (CI) was reported as the effect size. After adjustment for confounders, the odds of controlling LDL in women taking Lovastatin, Rosuvastatin, and Simvastatin were 0.27 (0.03, 0.45) lower in comparison with men. Also, in participant who took 3 types of statins, the odds of controlling LDL were significantly different between Lor and Arab compared with Fars ethnicity. After adjustment to all confounders (full model), the odds of controlling LDL were lower for Gilak in Lovastatin, Rosuvastatin, and Simvastatin by 0.64 (0.47, 0.75); 0.61 (0.43, 0.73); 0.63 (0.46, 0.74) respectively and higher for Arab in Lovastatin, Rosuvastatin, and Simvastatin by 4.63 (18.28, 0.73); 4.67 (17.47, 0.74); 4.55 (17.03, 0.71) respectively compared to Fars.

Conclusions

Major differences in different gender and ethnicities may have had led to disparities in statin use and LDL control. Awareness of the statins impact on high LDL cholesterol based on different ethnicities can help health decision-makers to close the observed gaps in statin use and control LDL to prevent CAD problems.

Antioxidant and antihyperlipidemic activity of Costus speciosus against atherogenic diet-induced hyperlipidemia in rabbits

OBJECTIVE

An extract of Costus speciosus (CSE), a herb widely used in folk medicine, was evaluated for its antioxidant, antihyperlipidemic and ameliorating effects on histopathological changes in atherogenic rabbits.

METHODS

Twenty-four male rabbits (Oryctolagus cuniculus) were divided into 4 groups. Three groups were fed a diet containing 3% saturated fat and 1.3% cholesterol for 40 d. One of these was sacrificed on the 40th day and was called the pathogenic (P) group; the other two groups received treatment for another 30 d as follows: one received 0.8 g/(kg·d) of CSE and the other was given 0.01 g/(kg·d) of simvastatin. The normal group was sacrificed on the 70th day and used as a control.

RESULTS

CSE showed radical-scavenging ability. Administration of CSE for a 30-day period resulted in a significant decrease in total cholesterol, triacylglycerol, low-density lipoprotein and aspartate aminotransferase compared to the P group, while levels of hemoglobin, packed corpuscular volume and red blood cells were elevated. With respect to studies performed on the heart, a decrease in malondialdehyde and an increase in reduced glutathione were noted. Total protein increased in the liver, heart and aorta after treatment with CSE and also a marked improvement in histopathological parameters was demonstrated.

CONCLUSION

The present findings indicate that the C. speciosus rhizome possesses antiatherogenic and antioxidant properties which may provide protective effects against oxidative stress in atherosclerotic rabbits.

Dietary modulators of statin efficacy in cardiovascular disease and cognition

Cardiovascular disease remains the leading cause of morbidity and mortality in the United States and other developed countries, and is fast growing in developing countries, particularly as life expectancy in all parts of the world increases. Current recommendations for the prevention of cardiovascular disease issued jointly from the American Academy of Cardiology and American Heart Association emphasize that lifestyle modification should be incorporated into any treatment plan, including those on statin drugs. However, there is a dearth of data on the interaction between diet and statins with respect to additive, complementary or antagonistic effects. This review collates the available data on the interaction of statins and dietary patterns, cognition, genetics and individual nutrients, including vitamin D, niacin, omega-3 fatty acids, fiber, phytochemicals (polyphenols and stanols) and alcohol. Of note, although the available data is summarized, the scope is limited, conflicting and disparate. In some cases it is likely there is unrecognized synergism. Virtually no data are available describing the interactions of statins with dietary components or dietary pattern in subgroups of the population, particularly those who may benefit most were positive effects identified. Hence, it is virtually impossible to draw any firm conclusions at this time. Nevertheless, this area is important because were the effects of statins and diet additive or synergistic harnessing the effect could potentially lead to the use of a lower intensity statin or dose.

Blood cholesterol trends 2001-2011 in the United States: analysis of 105 million patient records

Objectives

We report annual trends in low density lipoprotein cholesterol (LDL-C) from an in-care patient population of nearly 105 million adults across the United States (U.S.), from 2001 through 2011.

Background

Average blood cholesterol values have declined in the U.S. since at least 1960. The National Health and Nutrition Examination Survey (NHANES) reported declining blood cholesterol values from 1999 through 2010. In the absence of more recent published data, we examined LDL-C values from a single clinical laboratory database to determine whether these values continued to decline through 2011.

Methods and Results

We extracted almost 247 million LDL-C results from nearly 105 million adults who received diagnostic testing from a single national clinical laboratory. Annual age-adjusted mean LDL-C values were calculated, and analyzed by gender. Piecewise regression analysis of the total study population indicates a breakpoint, or change in slope, in the years following 2008 (F = 163.13; p<0.05). Between 2001 and 2008, the average rate of annual decline was −2.05 mg/dL (95% CI [−2.35, −1.75]). After 2008, mean LDL-C levels flattened out, with a slope not statistically different from zero (slope = −0.10 mg/dL/year; 95% CI [−1.46, 1.26]). This stabilization was observed in both genders and all age ranges, and was also reflected in the percentage of results in low- and high-risk categories.

Conclusions

The trends reported suggest historical progress in decreasing LDL-C levels, observed from 2001–2008, may have stalled in recent years. Further research is needed to determine the cause of the observed trends and develop new strategies to reduce lipid-based cardiovascular risk further.

2-methoxyestradiol inhibits atorvastatin-induced rounding of human vascular smooth muscle cells

The cardiovascular benefits of statins, including atorvastatin (ATV), have been reported to be gender-dependent, but the underlying mechanism is unclear. In this study we examine whether estrogen and its metabolite, 2-methoxyestradiol (2ME), affect the rounding response of human vascular smooth muscle cells (SMCs) induced by ATV. Twenty-four hour treatment with ATV (10-100 microM) induced rounding of cultured human SMCs. Addition of 2ME (1-20 microM), but not 17beta-estradiol, for 2 h induced re-spreading of rounded cells. Our further studies showed that the effects of 2ME were mimicked by microtubule-disrupting drugs and inhibited by taxol. Inhibition of RhoA and ROCK (Rho-kinase) by C3-toxin and H-1152, respectively, blocked 2ME effects. 2ME effects were also blocked by treatment with either actin-interfering drugs, such as cytochalasin D and jasplakinolide, or myosin inhibitor blebbistatin. ML-7 and -9, the inhibitors for myosin light chain kinase, inhibited 2ME effect as well. ATV treatment induced a decrease of F-actin content and Thr18/Ser19 dual phosphorylation of myosin regulatory light chain (MRLC), which was rescued by 2ME or mevalonate. The rescue effects of 2ME on F-actin content and MRLC dual phosphorylation were abolished by taxol or H-1152. In addition, kinesin Eg5 inhibitor monastrol and dynein inhibitor erythro-9-3-(2-hydroxynonyl) adenine (EHNA) significantly blocked 2ME effects. Finally, our results revealed that 2ME inhibited the migration of SMCs induced by ATV (0.1 microM) in wound healing assay and Boyden chamber assay. In summary, our data show that 2ME, but not estrogen, inhibits ATV-induced rounding of human SMCs through induction of microtubule disassembly and activation of the Rho-ROCK-actinomyosin pathway.

Modifications in dietary fat quality are associated with changes in serum lipids of older adults independently of lipid medication

Prospective evidence on the extent to which serum lipid concentrations in older persons respond to dietary modification is scarce. It is not clear whether such behavioral changes are relevant in the context of more commonly initiated treatments with lipid-lowering drugs. We therefore examined whether individual changes in the consumption of dietary fatty acids or main food sources were associated with changes in the serum lipid profile of older Australians. A total of 903 participants (> or =49 y) in the Blue Mountains Eye Study had complete data on fasting lipids and dietary intake from a validated FFQ at baseline (1992-1994) and 5- and 10-y follow-up examinations. Decreasing consumption of SFA and butter during the 10-y period were associated with moderate decreases in serum total cholesterol independently of initiation of lipid-lowering drug treatment [adjusted estimates were 0.018 +/- 0.007 mmol/(L x % energy (%en) from SFA (P = 0.01) and 0.055 +/- 0.015 mmol/(L x 5 g butter) (P = 0.0003), respectively]. Increased consumption of (n-3) fatty acids and fish was independently related to modest increases in serum HDL-cholesterol [0.067 +/- 0.026 mmol/(L x %en from (n-3) fatty acids) (P = 0.01) and 0.010 +/- 0.004 mmol/(L x 20 g fish) (P = 0.02)] and decreases in log-transformed serum triglyceride concentrations [P = 0.02 for (n-3) fatty acids and P = 0.02 for fish intake]. Hence, 10-y changes in the intake of dietary fatty acids and their food sources appear to have contributed to concurrent improvements in the serum lipid profile of older Australians, independent of concomitantly initiated lipid-lowering drug treatment.

Sex differences in the effectiveness of statins after myocardial infarction

BACKGROUND

We sought to investigate the sex differences in the effectiveness of statins in patients with acute myocardial infarction (AMI).

METHODS

Linking hospital discharge and drug claims databases from Quebec, Canada (1998-2004), we identified statin users (n = 14 710) and non-users (n = 23 833) discharged from hospital after an AMI-related hospital stay and followed up for as long as 7 years.

RESULTS

All-cause death rates were 4.1 and 14.6 per 100 person-years among users and non-users, respectively, whereas cardiac death rates were 2.2 and 7.4 per 100 person-years. For death from any cause, the adjusted hazard ratios associated with statin use in women were 0.61 (95% confidence interval [CI], 0.54-0.69) within 1 year of follow-up, 0.55 (0.48-0.63) at 1-3 years and 0.38 (0.31-0.49) at > 3 years; in men, the corresponding estimates were 0.54 (0.48-0.60), 0.48 (0.42-0.55) and 0.34 (0.30-0.39). For cardiac-related death, the adjusted hazard ratios associated with statin use in women were 0.70 (0.60-0.81) within 1 year, 0.56 (0.46-0.68) at 1-3 years and 0.44 (0.31-0.62) at > 3 years of follow-up, whereas in men, the estimates were 0.59 (0.51-0.69), 0.47 (0.39-0.58) and 0.37 (0.30-0.45), respectively.

INTERPRETATION

Statin therapy after an AMI was associated with reduced rates of all-cause and cardiac mortality. The effect increased with time in both sexes, but the degree of risk reduction was less for women than for men.

Endothelial Function in Healthy 11-Year-Old Children After Dietary Intervention With Onset in Infancy

Background— Early childhood introduction of nutritional habits aimed at atherosclerosis prevention reduces children’s serum total cholesterol concentration, but its effect on vascular endothelial function is unknown.

Methods and Results— Between 1990 and 1992, we randomized healthy 7-month-old infants (n=1062) to intervention (low-saturated-fat diet) and control (unrestricted diet) groups. At the age of 11 years, endothelium-dependent (flow-mediated) and endothelium-independent (nitrate-mediated) vasodilatory responses of the brachial artery were measured with high-resolution ultrasound in 179 intervention and 190 control children. The effect of intervention on endothelial function was significant in boys ( P =0.0034) but not in girls ( P =0.69). The maximum endothelium-dependent dilation response (mean±SD) was 9.62±3.53% and 8.36±3.85% in intervention boys and control boys and 8.84±4.00% and 8.44±3.60% in intervention girls and control girls, respectively. Intervention had no effect on nitrate-mediated dilation. The difference in endothelial function in boys remained significant after adjustment for current serum total or LDL cholesterol but became nonsignificant after adjustment for mean cholesterol measured under 3 years of age (adjusted means: 9.46% [CI 8.68% to 10.24%] versus 8.54% [CI 7.75% to 9.32%], P =0.11).

Conclusions— A low-saturated-fat diet introduced in infancy and maintained during the first decade of life is associated with enhanced endothelial function in boys. The effect is explained in part by the diet-induced reduction in serum cholesterol concentration.

Carbohydrates and dietary fiber

The most widely spread eating habit is characterized by a reduced intake of dietary fiber, an increased intake of simple sugars, a high intake of refined grain products, an altered fat composition of the diet, and a dietary pattern characterized by a high glycemic load, an increased body weight and reduced physical activity. In this chapter the effects of this eating pattern on disease risk will be outlined. There are no epidemiological studies showing that the increase of glucose, fructose or sucrose intake is directly and independently associated with an increased risk of atherosclerosis or coronary heart disease (CHD). On the other hand a large number of studies has reported a reduction of fatal and non-fatal CHD events as a function of the intake of complex carbohydrates--respectively 'dietary fiber' or selected fiber-rich food (e.g., whole grain cereals). It seems that eating too much 'fast' carbohydrate [i.e., carbohydrates with a high glycemic index (GI)] may have deleterious long-term consequences. Indeed the last decades have shown that a low fat (and consecutively high carbohydrate) diet alone is not the best strategy to combat modern diseases including atherosclerosis. Quantity and quality issues in carbohydrate nutrient content are as important as they are for fat. Multiple lines of evidence suggest that for cardiovascular disease prevention a high sugar intake should be avoided. There is growing evidence of the high impact of dietary fiber and foods with a low GI on single risk factors (e.g., lipid pattern, diabetes, inflammation, endothelial function etc.) as well as also the development of the endpoints of atherosclerosis especially CHD.

Men and Women Differ in Lipoprotein Response to Dietary Saturated Fat and Cholesterol Restriction

A diet restricted in saturated fat and cholesterol is recommended for subjects with elevated LDL cholesterol concentrations before and during drug therapy. Gender differences in lipoprotein subspecies response to such diets have not been studied in detail. We examined the effects of a diet low in total fat, saturated fat and cholesterol (Therapeutic Lifestyle Changes, TLC, diet: 26% of energy as fat, 4% as saturated fat, and 45 mg cholesterol/4.2 MJ), compared with an average American diet (AAD: 35% of energy as fat, 14% as saturated fat, and 147 mg cholesterol/4.2 MJ), on plasma lipoprotein subspecies in men and women. Each diet period lasted 6 wk. Body weight was kept constant during each diet period. Men (n = 19) and postmenopausal women (n = 14) >40 y old with moderate hypercholesterolemia participated in this study. Plasma lipoprotein concentrations were assessed by standardized methodology, and lipoprotein sizes were determined by gradient gel electrophoresis and NMR spectroscopy. The TLC diet resulted in greater reductions in total cholesterol and plasma apolipoprotein B concentrations in men than in women (-19% vs. -12%, P < 0.05, and -18% vs. -9%, P < 0.05, respectively). Postprandial triacylglycerol and LpAI:AII concentrations were reduced in men, but not in women (-15% vs. 8%, P < 0.05, and -9% vs. -2%, respectively, P < 0.05). Similar decreases in LpAI concentrations and LDL and HDL particle size were observed in men and women. These data are consistent with the concept that middle aged/elderly men may have a more favorable lipoprotein response to a low fat, low cholesterol diet than postmenopausal women.

Sustained reduction of serum cholesterol in low-dose 6-year simvastatin treatment with minimum side effects in 51,321 Japanese hypercholesterolemic patients

The Japan Lipid Intervention Trial (J-LIT) study, a nationwide cohort study utilizing the clinical practice of general physicians, was designed to clarify the relationship between the incidence of coronary heart disease and serum lipid concentrations during simvastatin therapy, as well as the safety of the therapy, in a large number of Japanese hypercholesterolemic patients. All the enrolled patients were treated with simvastatin. The current study analyzed the lipid lowering effect and safety of the low-dose simvastatin therapy used in the J-LIT study. Open-labeled simvastatin was given to 51,321 patients at an initial dose of mostly 5 mg/day. After 6 months of the treatment, the average serum total cholesterol (TC) and low density lipoprotein-cholesterol concentrations in all the patients followed up were reduced by 18.3% and 26.0%, respectively, and that of high density lipoprotein-cholesterol increased 2.3% on average. These concentrations were well maintained throughout the 6-year treatment period. A minority of patients (1.4%) unexpectedly had a remarkable reduction in TC concentration by more than 40%. Hyper-responders, even to low-dose statin, were found for the first time in this large-scale and long-term investigation. Overall adverse drug reactions occurred in 3.3% of subjects during the 6-year treatment, the major events being hepatic and musculoskeletal disorders, of which the incidence was less than 1%. Low-dose simvastatin therapy of 5 mg/day effectively controlled the serum TC concentration by reducing it by approximately 20% on average in hypercholesterolemic Japanese patients, a reduction that corresponds to the effect of simvastatin 20 mg/day in Western studies. In addition, the low incidence of drug-related adverse events in this study may be also related to the low dosage of simvastatin.

Diet and drug therapy: a dynamic duo for reducing coronary heart disease risk

A large proportion of the United States population requires aggressive low-density lipoprotein (LDL) cholesterol- lowering therapy to meet the new treatment guidelines established by the National Cholesterol Education Program Adult Treatment Panel III. This has further widened the gap between the number of people being treated compared with those who should be treated. Moreover, many people being treated do not meet their LDL cholesterol goal. Diet and healthy lifestyle practices remain the cornerstone of treatment to lower LDL cholesterol. Pharmacologic therapy has assumed an increasingly important role in reaching LDL cholesterol goals. Diet and healthy-lifestyle interventions have been shown to augment the benefits of cholesterol-lowering drugs. Together, this dynamic duo provides the most effective clinical means identified to date for maximally lowering LDL cholesterol levels.

Sex differences and the effects of sex hormones on hemostasis and vascular reactivity

Thrombus formation and vasospasm are involved in the initiation of acute ischemic events in the heart. Gender differences in persons with coronary artery disease and the incidence of myocardial ischemia have been clearly documented. In addition, it is well established that sex hormones influence the risk of developing coronary artery disease. Epidemiologic studies suggest that estrogen may exert a protective effect, yet the results of recently completed and ongoing prospective trials of estrogen and hormone (estrogen + progesterone) replacement suggest that these hormones can increase thrombotic events in postmenopausal women. This review focuses on sex (gender) differences in hemostasis and vascular reactivity and on the influence that sex hormones have on these physiologic systems. This review takes the novel approach of focusing on sex differences in hemostasis and vascular reactivity in healthy premenopausal women and men of a similar age. By comparing men and women in this age group, the confounding issues of age, pathology, or decline in sex hormone levels are avoided. Animal and in vitro investigations pertinent to examining potential cellular mechanism(s) of sex hormones in mediating these sex differences are discussed. We assume there is a relationship between the normal physiologic and pathologic effects of sex hormones; elucidating sex differences in normal cardiovascular function will help clarify the basis for sex differences in the incidence and manifestations of coronary heart disease and will aid in the future development of gender-specific therapies for cardiovascular disease.

Gender may affect the action of garlic oil on plasma cholesterol and glucose levels of normal subjects

Early trials of garlic preparations on blood lipids mainly supported a lipid-lowering effect, whereas later well-designed garlic tablet trials were mainly entirely null. However, enteric simulation tests suggest that this discordance may result from ineffective delivery of bioactive agents from the brands of garlic powder (GP) and cyclodextrin-bound garlic oil (GO) tablets tested in some recent negative trials. In contrast, enteric simulation tests show that the preformed bioactive agents present in "traditional" gelatin capsules of GO are efficiently released, although such capsules have rarely been investigated in lipid-lowering trials. It was hypothesized that gelatin capsules of GO given to normal subjects would improve specified coronary heart disease risk factors. Effects of a GP preparation were also investigated. Subjects (n = 51; men and women, mean age 27 y) were randomly assigned to receive either 8.2 mg/d of GO (allyl sulfides) or placebo for 11 wk. Another 27 subjects received garlic powder (GP) of similar biopotential (7.8 mg allicin/d). Outcome measures were 95% confidence intervals (CI) between GO and placebo groups for differences between baseline and subsequent sample times. Men and women combined showed no significant differences save for an improved total antioxidant capacity at 6 wk (P = 0.01). Hence, no benefit from GO after 11 wk is one plausible conclusion. However, there were significant differences in effect of GO between men and women for HDL cholesterol (HDL-C) (P = 0.004) and total cholesterol (TC)/HDL-C (P = 0.003). Women showed favorable effects in terms of CHD risk factors (i.e., increases in HDL-C and reductions in TC/HDL-C), whereas men had small adverse effects. There was a significant difference in the GO effect for glucose (P = 0.006), with a reduction seen for men and an increase for women. The gender effects were unexpected and such analyses were not planned in advance. Confirmation of these findings with larger numbers of subjects would have importance for the use of garlic against CHD and for the design of future garlic studies.

Diet and pravastatin in moderate hypercholesterolaemia: a randomized trial in 215 middle-aged men free from cardiovascular disease

OBJECTIVE

To evaluate the effect of diet and drug intervention separately and combined in the treatment of primary hypercholesterolemia.

DESIGN

The study was conducted as a randomized, placebo-controlled factorial trial, double-blinded for drug intervention.

SETTING

Subjects were recruited from a population-based cholesterol screening programme.

SUBJECTS

215 middle-aged men with primary hypercholesterolemia, free from cardiovascular disease.

INTERVENTIONS

Subjects were randomized to one of four intervention groups: (1) placebo and US National Cholesterol Education Program step 1 diet; (2) placebo and step 2 diet; (3) pravastatin 20 mg day-1 and step 1 diet; or (4) pravastatin 20 mg day-1 and step 2 diet. The intervention period was 6 months.

MAIN OUTCOME MEASUREMENTS

Efficacy measurements included: serum total cholesterol, HDL cholesterol, triglycerides, apolipoproteins A1 and B. LDL cholesterol was calculated. For safety, values of ALAT, ASAT and CK were measured.

RESULTS

In the group receiving the step 1 diet only, lipid values were stable during the study period. In the placebo group on the step 2 diet, total cholesterol decreased by 6.3% (0.47 mmol L-1 (95% CI: 0.28, 0.67)) during 6 months. In the group receiving both pravastatin and the step 1 diet, there was a mean reduction in serum total cholesterol of 19.4% (1.46 mmol L-1 (95% CI: 1.20, 1.72)). In the group treated with pravastatin and the step 2 diet, the 6 months of data show a reduction of 20.7% (1.55 mmol L-1 (95% CI: 1.30, 1.80)).

CONCLUSIONS

If drug therapy with a HMG-CoA reductase inhibitor is considered necessary, a step 2 diet has no additional lipid-lowering effect compared with a step 1 diet in men with primary hypercholesterolaemia. However, favourable 'side-effects' of a lipid-lowering diet, such as weight loss and lowering of blood pressure, may still warrant a low-fat diet in these cases.

Efficacy of simvastatin and pumpkin-seed oil in the management of dietary-induced hypercholesterolemia

Pumpkin-seed oil (PSO), a natural supplement rich with antioxidants and polyunsaturated fatty acids (PUFAs), was given in combination with simvastatin, as antihypercholesterolemic drug, to high cholesterol-fed rabbits, for three weeks. In comparison with normal rabbits, a significant increase of the aortic contractile response to norepinephrine was observed which could be attributed to endothelium dysfunction. In addition, serum levels of total lipids, triacylglycerols, total cholesterol and low density lipoprotein-cholesterol (LDL-C) were increased while phospholipids and high density lipoprotein-cholesterol (HDL-C) were decreased in hypercholesterolemic rabbits. These changes could be related to the predominance of LDL and oxidized-LDL particles caused by high levels of reactive oxygen species during hypercholesterolemia (HC). Treatment with simvastatin modulated most of the altered parameters affected during HC that might be, in part, due to inhibition of cholesterol biosynthesis. While concomitant administration of simvastatin and PSO succeeded to cause marked reduction of the aortic contractile response to norepinephrine and to normalize the most adverse effects observed during HC. These effects were explained by the potentiating effects of simvastatin with antioxidants and essential fatty acids in PSO. On the contrary, serum activities of aminotransferases and creatine phosphokinase were increased with simvastatin treatment but not with the combination therapy in hypercholesterolemic rabbits.

Simvastatin. A reappraisal of its pharmacology and therapeutic efficacy in hypercholesterolaemia

Simvastatin is an HMG-CoA reductase inhibitor used in the treatment of patients with hypercholesterolaemia. Since the time simvastatin was previously reviewed in Drugs, a number of large clinical trials have confirmed its clinical efficacy. Thus, reductions from baseline were approximately 20 to 40% for serum levels of total cholesterol, 35 to 45% for low density lipoprotein (LDL)-cholesterol and 10 to 20% for triglycerides in patients with primary hypercholesterolaemia receiving simvastatin 10 to 40 mg/day. High density lipoprotein (HDL)-cholesterol levels were increased modestly by about 5 to 15%. Recent data from long term studies indicate that little or no attenuation of these changes in serum lipid and lipoprotein levels occurred with administration of simvastatin for 3 to 5.4 years. Comparative studies with other HMG-CoA reductase inhibitors (lovastatin, pravastatin and fluvastatin), which were lacking at the time of the previous review of simvastatin, demonstrated greater reductions in serum levels of total cholesterol and LDL-cholesterol with simvastatin than equal dosages of lovastatin or pravastatin. Reductions in serum levels of total cholesterol and LDL-cholesterol were similar between agents only when lovastatin or pravastatin were administered at a total daily dosage twice that of simvastatin and when fluvastatin was administered at a total daily dosage approximately 8 times that of simvastatin. In general, simvastatin 10 to 40 mg/day was also more effective than standard dosages of bile acid sequestrants, fibrates or probucol in lowering serum levels of total cholesterol and LDL-cholesterol; however, fibrates usually produced greater reductions in serum triglycerides and greater elevations in HDL-cholesterol levels. The Scandinavian Simvastatin Survival Study (4S), a large secondary prevention study in patients with coronary heart disease and concomitant hypercholesterolaemia, demonstrated that simvastatin 20 to 40 mg/day for a median of 5.4 years significantly reduced overall mortality (the primary end-point of the study) by 30% compared with placebo, which was attributed to a 42% relative reduction in coronary mortality. Coronary morbidity was also significantly reduced by simvastatin in the 4S trial. The tolerability profile of simvastatin appears to be comparable to that of other HMG-CoA reductase inhibitors. The most frequently reported adverse events are gastrointestinal disturbances, which are generally mild and tend to occur less frequently than with cholestyramine. In conclusion, simvastatin is among the most effective agents available for treating patients with hypercholesterolaemia.(ABSTRACT TRUNCATED AT 400 WORDS)