Prevalence of Low Low-Density Lipoprotein Cholesterol With Elevated High Sensitivity C-Reactive Protein in the U.S

The inflammatory state is a risk factor for cardiovascular disease and graft fibrosis in kidney transplantation

Several factors, such as donor brain death, ischemia-reperfusion injury, rejection, infection, and chronic allograft dysfunction, may induce an inflammatory state in kidney transplantation. Furthermore, inflammatory cells, cytokines, growth factors, complement and coagulation cascade create an unbalanced interaction with innate and adaptive immunity, which are both heavily involved in atherogenesis. The crosstalk between inflammation and thrombosis may lead to a prothrombotic state and impaired fibrinolysis in kidney transplant recipients increasing the risk of cardiovascular disease. Inflammation is also associated with elevated levels of fibroblast growth factor 23 and low levels of Klotho, which contribute to major adverse cardiovascular events. Hyperuricemia, glucose intolerance, arterial hypertension, dyslipidemia, and physical inactivity may create a condition called metaflammation that concurs in atherogenesis. Another major consequence of the inflammatory state is the development of chronic hypoxia that through the mediation of interleukins 1 and 6, angiotensin II, and transforming growth factor beta can result in excessive accumulation of extracellular matrix, which can disrupt and replace functional parenchyma, leading to interstitial fibrosis and chronic allograft dysfunction. Lifestyle and regular physical activity may reduce inflammation. Several drugs have been proposed to control the graft inflammatory state, including low-dose aspirin, statins, renin-angiotensin inhibitors, xanthine-oxidase inhibitors, vitamin D supplements, and interleukin-6 blockade. However, no prospective controlled trial with these measures has been conducted in kidney transplantation.

High-Sensitivity C-Reactive Protein Discordance With Atherogenic Lipid Measures and Incidence of Atherosclerotic Cardiovascular Disease in Primary Prevention: The ARIC Study

Background Inflammation is an independent causal risk factor for atherosclerotic cardiovascular diseases (ASCVDs). However, whether hsCRP (high-sensitivity C-reactive protein) is prognostic across various levels of atherogenic lipid measures such as low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B and total cholesterol/high-density lipoprotein cholesterol in primary prevention is unknown. Methods and Results We studied 9748 ARIC (Atherosclerosis Risk in Communities) study participants who were free of ASCVD at baseline (visit 4, 1996-1998) and had measurements of lipids, apolipoprotein B, and hsCRP. We used multivariable adjusted Cox models to estimate the risk of incident ASCVD events associated with hsCRP levels (less than/greater than or equal to median) in individuals where triple lipid measures combined (low-density lipoprotein cholesterol + non-high-density lipoprotein cholesterol + apolipoprotein B) or quadruple measures combined [triple + total cholesterol/high-density lipoprotein cholesterol] were less than versus greater than or equal to median cut points. Mean age of participants was 62.6±5.6 years; 59% women, 22% black. There were 1574 ASCVD events over median (interquartile range) follow-up of 18.4 (12.8-19.5) years, and discordance between hsCRP and lipid measures was prevalent in 50% of the population. hsCRP greater than or equal to median (2.4 mg/L), compared with less than median, was associated with an increased risk of ASCVD in individuals with less than median levels of the triple (adjusted hazard ratio, 1.33; 95% CI, 1.09-1.60) and quadruple (adjusted hazard ratio,1.47; 95% CI, 1.18-1.85) lipid measures. Such increased risk was consistent among individuals with low (<7.5%) or high (≥7.5%) estimated risk by the pooled cohort equation. There were no interactions by sex, diabetes mellitus, or statin use. Conclusions Our findings suggest that inflammation is independently associated with ASCVD regardless of atherogenic lipid levels and pooled cohort equation risk score in individuals without known ASCVD.

Prevalence and predictors of elevated high-sensitivity C-reactive protein in post-myocardial infarction patients: Insights from the VIRGO and TRIUMPH registries

Elevated high-sensitivity C-reactive protein (hs-CRP) is associated with worse cardiovascular outcomes in patients with acute myocardial infarction (AMI), but little is known about the distribution of hs-CRP levels and predictors of elevated hs-CRP after AMI in the real world. Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) and Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) are prospective AMI registries in the United States that assessed hs-CRP levels 30 days after AMI. TRIUMPH additionally assessed hs-CRP levels at the time of AMI and at 6 months. Hierarchical models were built to examine predictors of elevated hs-CRP (≥2.0 mg/L) at 30 days in both registries and at 6 months after AMI in TRIUMPH. Of 3410 patients in both registries, 58.6% had elevated hs-CRP 30 days after AMI. Patients with elevated hs-CRP at 30 days were more likely to be older, female, obese, smokers, report financial difficulties, and have higher low-density lipoprotein cholesterol levels on admission, diabetes, and hypertension. In TRIUMPH, baseline hs-CRP ≥2 mg/L (n = 1301) was significantly associated with elevated hs-CRP at follow-up (P < 0.001). Similar associations were found in TRIUMPH patients with elevated hs-CRP at 6 months. Our study identified a high prevalence and several patient characteristics associated with elevated hs-CRP at 1 and 6 months after discharge. Further studies to test routine screening after AMI may be warranted to identify higher-risk patients for more aggressive secondary prevention.

A Comparative Study of High Sensitivity C-Reactive Protein and Metabolic Variables in Type 2 Diabetes Mellitus with and without Nephropathy

Introduction

Diabetic nephropathy is a serious chronic complication of Type 2 Diabetes Mellitus (T2DM) which impairs the quality of life, leading to increased morbidity and mortality. The high sensitivity C-reactive protein (hs-CRP) is an acute phase reactant which acts as a non-specific systemic marker of inflammation.

Aim

To find out the relationship between serum hs-CRP and metabolic variables in Type 2 diabetic patients with and without nephropathy.

Materials and Methods

The study group consists of 96 subjects that include non-diabetic healthy controls, Type 2 diabetic patients without any complications and patients with diabetic nephropathy. The study group was composed of both genders, aged 31-70 years, who reported after 10-12 hours overnight fasting; then, venous blood and fresh urine samples were collected, in the morning from all the study subjects. Data were analysed using Statistical Package for the Social Sciences (SPSS). Independent t-test was used to compare between the groups and Chi square test was used to find out the relationship between serum hs-CRP and metabolic variables.

Results

The results showed a significantly (p<0.05) increasing trend of serum hs-CRP with the degree of microalbumin excretion and the severity of nephropathy in Type 2 diabetic patients. The result showed a significant (p<0.05) relationship between hs-CRP and the metabolic variables like Fasting Blood Glucose (FBG), Post Prandial Blood Glucose (PPBG), Total Cholesterol (TC), Triglycerides (TG), LDL-Cholesterol (LDL-C), TC:HDL-Cholesterol (HDL-C) ratio and estimated Glomerular Filtration Rate (eGFR) and no significance (p>0.05) between hs-CRP and HDL-Cholesterol in both diabetic and diabetic nephropathy subjects.

Conclusion

Hs-CRP was strongly associated with the metabolic variables and predictors of cardiovascular risk in Type 2 diabetes mellitus with and without nephropathy. The hs-CRP might be considered as a predictor or illness indicator for the development of nephropathy and cardiovascular risk in Type 2 diabetic patients.

Atherogenic Lipoprotein Determinants of Cardiovascular Disease and Residual Risk Among Individuals With Low Low-Density Lipoprotein Cholesterol

Background

Levels of LDL (low‐density lipoprotein) cholesterol in the population are declining, and increasing attention is being focused on residual lipid‐related pathways of atherosclerotic cardiovascular disease risk beyond LDL cholesterol. Among individuals with low (<130 mg/dL) LDL cholesterol, we undertook detailed profiling of circulating atherogenic lipoproteins in relation to incident cardiovascular disease in 2 populations.

Methods and Results

We performed proton nuclear magnetic resonance spectroscopy to quantify concentrations of LDL and VLDL (very low‐density lipoprotein) particle subclasses in 11 984 JUPITER trial participants (NCT00239681). Adjusted Cox models examined cardiovascular disease risk associated with lipoprotein measures according to treatment allocation. Risk (adjusted hazard ratio [95%CI] per SD increment) among placebo‐allocated participants was associated with total LDL particles (1.19 [1.02, 1.38]) and total VLDL particles (1.21 [1.04, 1.41]), as well as apolipoprotein B, non–high‐density lipoprotein cholesterol, and triglycerides, but not LDL‐c. Rosuvastatin reduced LDL measures but had variable effects on triglyceride and VLDL measures. On‐statin levels of the smallest VLDL particle subclass were associated with a 68% per‐SD (adjusted hazard ratio 1.68 [1.28, 2.22]) increase in residual risk—this risk was related to VLDL cholesterol and not triglyceride or larger VLDL particles. There was evidence that residual risk prediction during statin therapy could be significantly improved through the inclusion of key VLDL measures (Harrell C‐index 0.780 versus 0.712; P<0.0001). In an independent, prospective cohort of 4721 individuals referred for cardiac catheterization (CATHGEN), similar patterns of lipoprotein‐related risk were observed.

Conclusions

Atherogenic lipoprotein particle concentrations were associated with cardiovascular disease risk when LDL cholesterol was low. VLDL lipoproteins, particularly the smallest remnant subclass, may represent unused targets for risk prediction and potential therapeutic intervention for reducing residual risk.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00239681.

Cost-effectiveness and cost-utility analysis of OTC use of simvastatin 10 mg for the primary prevention of myocardial infarction in Iranian men

Background

Several clinical trials and meta-analyses have shown the advantageous effects of statins in populations with different levels of cardiovascular disease (CVD) risk. Considering the increasing cardiovascular risk among the Iranian population, the cost-effectiveness of the use of simvastatin 10 mg, as an Over-The-Counter (OTC) drug, for the primary prevention of myocardial infarction (MI) was evaluated in this modeling study, from the payer's perspective. The target population is a hypothetical cohort of 45-year CVD healthy men with an average (15 %) 10-year CVD risk.

Methods

A semi-Markov model with a life-long time horizon was developed to evaluate the Cost-Utility-Analysis (CUA) and Cost-Effectiveness-Analysis (CEA) of the use of OTC simvastatin 10 mg compared to no-drug therapy. Two measures of benefits were used in the model; Quality-Adjusted-Life-Years (QALYs) for the CUA and Life-Years-Gained (LYG) for the CEA. To examine the robustness of the results, one-way sensitivity analysis and probabilistic sensitivity analysis were applied to the model.

Results

For the base-case scenario with a discount rate of 0 % the estimated ICERs were 1113 USD/QALY and 935USD/LYG per patient (using governmental tariffs).

No threshold has been determined in Iran for the cost-effectiveness of health-related interventions. However, according to the recommendation of WHO, this intervention can be considered highly cost-effective as its ICER is far less than the reported GDP per capita for Iran by World bank in 2013 ($4763).

Conclusions

This modeling study showed that the use of an OTC low dose statin (simvastatin 10 mg) for the primary prevention of myocardial infarction (MI) in 45-year men with a 10-year CVD risk of 15 % could be considered highly cost-effective in Iran, as it meets the WHO threshold of the annual GDP per capita ($4763).

Trends in low-density lipoprotein cholesterol goal achievement in high risk United States adults: longitudinal findings from the 1999-2008 National Health and Nutrition Examination Surveys

BACKGROUND

Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among U.S. individuals at high cardiovascular disease risk; however, recent studies in selected populations indicate improvements.

OBJECTIVE

We sought to define the longitudinal trends in achieving LDL-C goals among high-risk United States adults from 1999-2008.

METHODS

We analyzed five sequential population-based cross-sectional National Health and Nutrition Examination Surveys 1999-2008, which included 18,656 participants aged 20-79 years. We calculated rates of LDL-C goal achievement and treatment in the high-risk population.

RESULTS

The prevalence of high-risk individuals increased from 13% to 15.5% (p = 0.046). Achievement of LDL-C <100 mg/dL increased from 24% to 50.4% (p<0.0001) in the high-risk population with similar findings in subgroups with (27% to 64.8% p<0.0001) and without (21.8% to 43.7%, p<0.0001) coronary heart disease (CHD). Achievement of LDL-C <70 mg/dL improved from 2.4% to 17% (p<0.0001) in high-risk individuals and subgroups with (3.4% to 21.4%, p<0.0001) and without (1.7% to 14.9%, p<0.0001) CHD. The proportion with LDL-C ≥130 mg/dL and not on lipid medications decreased from 29.4% to 18% (p = 0.0002), with similar findings among CHD (25% to 11.9% p = 0.0013) and non-CHD (35.8% to 20.8% p<0.0001) subgroups.

CONCLUSION

The proportions of the U.S. high-risk population achieving LDL-C <100 mg/dL and <70 mg/dL increased over the last decade. With 65% of the CHD subpopulation achieving an LDL-C <100 mg/dL in the most recent survey, U.S. LDL-C goal achievement exceeds previous reports and approximates rates achieved in highly selected patient cohorts.

Prevalence of low LDL-cholesterol levels and elevated high-sensitivity C-reactive protein levels in apparently healthy Korean adults

BACKGROUND AND AIMS

The Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) reported reduced cardiovascular and all-cause mortality in patients with elevated C-reactive protein (CRP) and low LDL-cholesterol (LDL-C) levels treated with statins. The aims of this study were to determine the proportion of "JUPITER-eligible" Korean adults and to describe their characteristics.

METHODS AND RESULTS

As many as 15,154 subjects with serum LDL-C levels <130 mg/dL were selected among 28,851 middle-aged participants (men ≥ 50 years, women ≥ 60 years) who participated in a routine health check-up program. Among the participants with LDL-C less than 130 mg/dL, only 15% had CRP levels ≥2.0 mg/L (7.9% of original participants). Subjects were divided into four groups according to CRP levels (<0.5, ≥0.5 - <1.0, ≥1.0 - <2.0, and ≥2.0 mg/L). Mean HDL-C and apolipoprotein A1 levels decreased significantly as the mean CRP values increased. The insulin and homeostasis model of insulin resistance was significantly different according to CRP quartile. The number of subjects with metabolic syndrome and its components increased significantly as the mean CRP values increased.

CONCLUSION

In this Asian population, few individuals with low LDL-C levels had CRP levels ≥2.0 mg/L. Elevated CRP levels were associated with components of atherogenic dyslipidemia and insulin resistance. Additional clinical trials should be designed and performed in different ethnic groups, as different CRP cut-off levels may be required in different ethnic groups.

Women up, men down: the clinical impact of replacing the Framingham Risk Score with the Reynolds Risk Score in the United States population

Background

The Reynolds Risk Score (RRS) is one alternative to the Framingham Risk Score (FRS) for cardiovascular risk assessment. The Adult Treatment Panel III (ATP III) integrated the FRS a decade ago, but with the anticipated release of ATP IV, it remains uncertain how and which risk models will be integrated into the recommendations. We sought to define the effects in the United States population of a transition from the FRS to the RRS for cardiovascular risk assessment.

Methods

Using the National Health and Nutrition Examination Surveys, we assessed FRS and RRS in 2,502 subjects representing approximately 53.6 Million (M) men (ages 50–79) and women (ages 45–79), without cardiovascular disease or diabetes. We calculated the proportion reclassified by RRS and the subset whose LDL-C goal achievement changed.

Results

Compared to FRS, the RRS assigns a higher risk category to 13.9% of women and 9.1% of men while assigning a lower risk to 35.7% of men and 2% of women. Overall, 4.7% of women and 1.1% of men fail to meet newly intensified LDL-C goals using the RRS. Conversely, 10.5% of men and 0.6% of women now meet LDL-C goal using RRS when they had not by FRS.

Conclusion

In the U.S. population the RRS assigns a new risk category for one in six women and four of nine men. In general, women increase while men decrease risk. In conclusion, adopting the RRS for the 53.6 million eligible U.S. adults would result in intensification of clinical management in 1.6 M additional women and 2.10 M fewer men.

C-reactive protein level and the incidence of eligibility for statin therapy: the multi-ethnic study of atherosclerosis

BACKGROUND

Given the results of the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial, statin initiation may be considered for individuals with elevated high-sensitivity C-reactive protein (hsCRP). However, if followed prospectively, many individuals with elevated CRP may become statin eligible, limiting the impact of elevated CRP as a treatment indication. This analysis estimates the proportion of people with elevated CRP that become statin eligible over time.

HYPOTHESIS

Most people with elevated CRP become statin eligible over a short period of time.

METHODS

We followed 2153 Multi-Ethnic Study of Atherosclerosis (MESA) participants free of cardiovascular disease and diabetes with low-density lipoprotein cholesterol <130 mg/dL at baseline to determine the proportion who become eligible for statins over 4.5 years. The proportion eligible for statin therapy, defined by the National Cholesterol Education Program (NCEP) 2004 updated guidelines, was calculated at baseline and during follow-up stratified by baseline CRP level (≥2 mg/L).

RESULTS

At baseline, 47% of the 2153 participants had elevated CRP. Among participants with elevated CRP, 29% met NCEP criteria for statins, compared with 28% without elevated CRP at baseline. By 1.5 years later, 26% and 22% (P = 0.09) of those with and without elevated CRP at baseline reached NCEP low-density lipoprotein cholesterol criteria and/or had started statins, respectively. These increased to 42% and 39% (P = 0.24) at 3 years and 59% and 52% (P = 0.01) at 4.5 years following baseline.

CONCLUSIONS

A substantial proportion of those with elevated CRP did not achieve NCEP-based statin eligibility over 4.5 years of follow-up. These findings suggest that many patients with elevated CRP may not receive the benefits of statins if CRP is not incorporated into the NCEP screening strategy.

The JUPITER trial: myth or reality?

The JUPITER trial is widely hailed as a landmark trial that has the potential to dramatically change the landscape of primary prevention of cardiovascular disease. Like most trials, however, it is not without its limitations. We address some of the common myths and misunderstandings that are underscored by the JUPITER trial. First, by its intentional and ill-advised exclusion of patients with low levels of high-sensitivity C-reactive protein (hsCRP), it is not possible to assess whether baseline hsCRP modifies treatment response to statins or whether it identifies patients most likely to benefit from statin therapy. Second, by stopping the trial early, one cannot rule out the possibility that the treatment benefit was overestimated and risk was underestimated, thereby precluding a reliable estimate of benefit/risk. Finally, as a consequence of early stopping, it is not possible to reliably assess the cost-effectiveness of primary prevention with rosuvastatin. Given these limitations, the attendant societal health policy implications remain largely unknown.

Influence and critique of the JUPITER Trial (Statins v no statins for primary prevention of cardiovascular events in patients with normal lipids and elevated C-reactive protein)

Perhaps no recent trial in primary prevention of cardiovascular disease has resulted in more controversy than the JUPITER (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin) trial, which was first published in 2008. The study evaluated a patient cohort previously considered to be "healthy," ie, men 50 years of age or older and women 60 years of age or older, who did not have a history of cardiovascular disease and, at the initial screening visit, had a low-density lipoprotein cholesterol level of <130 mg/dL (3.4 mmol/L) and a high-sensitivity C-reactive protein level ≥2.0 mg/L. The trial showed that rosuvastatin is a powerful statin that, at lower doses, can reduce low-density lipoprotein cholesterol to levels previously not seen with other agents. Concurrently, it can also reduce high-sensitivity C-reactive protein to levels below what are considered normal, but that might be more physiologic. In the trial participants who achieved such lowering, major cardiovascular events, including venous thromboembolic events, were reduced even in the short term. Despite these results, many still question whether the trial results should influence high-sensitivity C-reactive protein testing or the prescription of statins for individuals at low risk for cardiovascular disease.

Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study

BACKGROUND

The JUPITER trial showed that some patients with LDL-cholesterol concentrations less than 3·37 mmol/L (<130 mg/dL) and high-sensitivity C-reactive protein (hsCRP) concentrations of 2 mg/L or more benefit from treatment with rosuvastatin, although absolute rates of cardiovascular events were low. In a population eligible for JUPITER, we established whether coronary artery calcium (CAC) might further stratify risk; additionally we compared hsCRP with CAC for risk prediction across the range of low and high hsCRP values.

METHODS

950 participants from the Multi-Ethnic Study of Atheroslcerosis (MESA) met all criteria for JUPITER entry. We compared coronary heart disease and cardiovascular disease event rates and multivariable-adjusted hazard ratios after stratifying by burden of CAC (scores of 0, 1-100, or >100). We calculated 5-year number needed to treat (NNT) by applying the benefit recorded in JUPITER to the event rates within each CAC strata.

FINDINGS

Median follow-up was 5·8 years (IQR 5·7-5·9). 444 (47%) patients in the MESA JUPITER population had CAC scores of 0 and, in this group, rates of coronary heart disease events were 0·8 per 1000 person-years. 74% of all coronary events were in the 239 (25%) of participants with CAC scores of more than 100 (20·2 per 1000 person-years). For coronary heart disease, the predicted 5-year NNT was 549 for CAC score 0, 94 for scores 1-100, and 24 for scores greater than 100. For cardiovascular disease, the NNT was 124, 54, and 19. In the total study population, presence of CAC was associated with a hazard ratio of 4·29 (95% CI 1·99-9·25) for coronary heart disease, and of 2·57 (1·48-4·48) for cardiovascular disease. hsCRP was not associated with either disease after multivariable adjustment.

INTERPRETATION

CAC seems to further stratify risk in patients eligible for JUPITER, and could be used to target subgroups of patients who are expected to derive the most, and the least, absolute benefit from statin treatment. Focusing of treatment on the subset of individuals with measurable atherosclerosis could allow for more appropriate allocation of resources.

FUNDING

National Institutes of Health-National Heart, Lung, and Blood Institute.

JUPITER and satellites: Clinical implications of the JUPITER study and its secondary analyses

THE JUSTIFICATION FOR THE USE OF STATINS IN PREVENTION: an intervention trial evaluating rosuvastatin (JUPITER) study was a real breakthrough in primary cardiovascular disease prevention with statins, since it was conducted in apparently healthy individuals with normal levels of low-density lipoprotein cholesterol (LDL-C < 130 mg/dL) and increased inflammatory state, reflected by a high concentration of high-sensitivity C-reactive protein (hs-CRP ≥ 2 mg/L). These individuals would not have qualified for statin treatment according to current treatment guidelines. In JUPITER, rosuvastatin was associated with significant reductions in cardiovascular outcomes as well as in overall mortality compared with placebo. In this paper the most important secondary analyses of the JUPITER trial are discussed, by focusing on their novel findings regarding the role of statins in primary prevention. Also, the characteristics of otherwise healthy normocholesterolemic subjects who are anticipated to benefit more from statin treatment in the clinical setting are discussed. Subjects at "intermediate" or "high" 10-year risk according to the Framingham score, those who exhibit low post-treatment levels of both LDL-C (< 70 mg/dL) and hs-CRP (< 1 mg/L), who are 70 years of age or older, as well as those with moderate chronic kidney disease (estimated glomerular filtration rate < 60 mL/min every 1.73 m(2)) are anticipated to benefit more from statin treatment. Unlikely other statin primary prevention trials, JUPITER added to our knowledge that statins may be effective drugs in the primary prevention of cardiovascular disease in normocholesterolemic individuals at moderate-to-high risk. Also, statin treatment may reduce the risk of venous thromboembolism and preserve renal function. An increase in physician-reported diabetes represents a major safety concern associated with the use of the most potent statins.

The cost-effectiveness of C-reactive protein testing and rosuvastatin treatment for patients with normal cholesterol levels

OBJECTIVES

We sought to evaluate the cost-effectiveness of applying the JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial results into clinical practice.

BACKGROUND

The JUPITER trial found that rosuvastatin reduces vascular events in apparently healthy subjects with elevated high-sensitivity C-reactive protein (hs-CRP) but normal low-density lipoprotein (LDL) cholesterol levels. The implications of expanding treatment recommendations based on these results have not been evaluated.

METHODS

We constructed a cost-effectiveness model of men ≥ 50 years and women ≥ 60 years with LDL cholesterol levels of <130 mg/dl and no known cardiovascular disease. We compared: 1) hs-CRP testing followed by rosuvastatin treatment for patients with hs-CRP levels ≥ 2.0 mg/l; and 2) usual care (i.e., no testing and no treatment). Estimates of treatment effectiveness were based on the JUPITER trial and were varied in sensitivity analyses.

RESULTS

Among patients with LDL <130 mg/dl and hs-CRP levels ≥ 2.0 mg/l, rosuvastatin had an incremental cost-effectiveness of $25,198 per quality-adjusted life year (QALY) gained compared to usual care. If the effectiveness of rosuvastatin were 50% of that observed in JUPITER, the incremental cost-effectiveness ratio would increase to $50,871 per QALY. Implementing this strategy only in patients with a Framingham risk score ≥ 10% yielded an incremental cost-effectiveness of $14,205 per QALY. Among such intermediate-risk patients, a JUPITER-based strategy becomes cost-saving at a rosuvastatin price of < $0.86 per day.

CONCLUSIONS

Rosuvastatin treatment for JUPITER-eligible patients appears to be cost-effective, particularly among those with a Framingham risk score ≥ 10%.

The population effects of the global cardiovascular risk model in United States adults: findings from the National Health and Nutrition Surveys, 2005-2006

BACKGROUND

The Framingham Global Cardiovascular Disease (FRS-CVD) risk assessment is a proposed alternative for the assessment of hard coronary heart disease (FRS-CHD) event risk. Beyond heart attack and death, FRS-CVD risk adds the end points of cerebrovascular disease, angina, heart failure, and peripheral vascular disease.

OBJECTIVE

We sought to estimate the population impact of using FRS-CVD instead of FRS-CHD risk prediction on U.S. adults.

METHODS

We analyzed FRS-CHD and FRS-CVD risk in men age 45-74 and women age 55-74 without cardiovascular disease or diabetes, using the National Health and Nutrition Examination Survey 2005-2006. We stratified the population into 10-year risk categories: low: <6%, moderate ≥ 6 to <10%, moderate high ≥ 10 to <20%, and high ≥ 20% by both risk models, and assessed change in risk category distribution and achievement of lipid goals.

RESULTS

We analyzed 1020 subjects who statistically represent approximately 50 million U.S. adults. When the FRS-CVD was used, we found that 63% of men and 74% of women increase at least one risk category compared with when the FRS-CHD is used. Overall, the low-risk population decreases from 52% to 16% and the high-risk group increases from 4% to 20%. Of the subjects changing risk categories, 30% will now fail to meet their new corresponding lipid goals.

CONCLUSIONS

FRS-CVD end points are more comprehensive, yet the population implications of such a change may be profound. The use of a FRS-CVD risk model significantly increases the intermediate and high-risk groups, thus increasing the number of individuals eligible for novel risk assessment tools such as high-sensitivity C-reactive protein, coronary calcium scoring, and more frequent use of pharmacotherapy.

Public health impact of statin prescribing strategies based on JUPITER

OBJECTIVE

To evaluate the public health impact of statin prescribing strategies based on the Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin Study (JUPITER).

METHODS

We studied 2268 adults aged 35-75 without cardiovascular disease in a population-based study in Switzerland in 2003-2006. We assessed the eligibility for statins according to the Adult Treatment Panel III (ATPIII) guidelines, and by adding "strict" (hs-CRP≥2.0 mg/L and LDL-cholesterol <3.4 mmol/L), and "extended" (hs-CRP≥2.0 mg/L alone) JUPITER-like criteria. We estimated the proportion of CHD deaths potentially prevented over 10 years in the Swiss population.

RESULTS

Fifteen percent were already taking statins, 42% were eligible by ATPIII guidelines, 53% by adding "strict," and 62% by adding "extended" criteria, with a total of 19% newly eligible. The number needed to treat with statins to avoid one CHD death over 10 years was 38 for ATPIII, 84 for "strict" and 92 for "extended" JUPITER-like criteria. ATPIII would prevent 17% of CHD deaths, compared with 20% for ATPIII+"strict" and 23% for ATPIII + "extended" criteria (+6%).

CONCLUSION

Implementing JUPITER-like strategies would make statin prescribing for primary prevention more common and less efficient than it is with current guidelines.

Clinical utility of rosuvastatin and other statins for cardiovascular risk reduction among the elderly

Age is one of the strongest predictors of cardiovascular disease (CVD) risk. Treatment with statins can significantly reduce CVD events and mortality in both primary and secondary prevention. Yet despite the high CVD risk among the elderly, there is underutilization of statins in this population (ie, the treatment-risk paradox). Few studies have investigated the use of statins in the elderly, particularly for primary prevention and, as a result, guidelines for treating the elderly are limited. This is likely due to: uncertainties of risk assessment in older individuals where the predictive value of individual risk factors is decreased; the need to balance the benefits of primary prevention with the risks of polypharmacy, health care costs, and adverse medication effects in a population with decreased life expectancy; the complexity of treating patients with many other comorbidities; and increasingly difficult social and economic concerns. As life expectancy increases and the total elderly population grows, these issues become increasingly important. JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) is the largest primary prevention statin trial to date and enrolled a substantial number of elderly adults. Among the 5695 JUPITER participants ≥ 70 years of age, the absolute CVD risk reduction associated with rosuvastatin was actually greater than for younger participants. The implications of this JUPITER subanalysis and the broader role of statins among older adults is the subject of this review.

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.

Cost-effectiveness of statin therapy for vascular event prevention in adults with elevated C-reactive protein: implications of JUPITER

OBJECTIVES

High-sensitivity C-reactive protein (hs-CRP) has been explored for use in predicting cardiovascular risk. The recent Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study found that statin therapy reduced cardiovascular events in those with low-density lipoprotein (LDL) cholesterol levels below current treatment thresholds (≤130 mg/dL, 3.4 = mmol/L), but with elevated hs-CRP levels (≥2.0 mg/L). This study examines the cost-effectiveness of statin treatment for individuals with elevated hs-CRP but normal LDL cholesterol.

METHODS

A Markov decision-analytic model was conducted from the U.S. societal perspective. Data from JUPITER were used to estimate rates of myocardial infarction, angina and stroke. Statin costs were based on generic simvastatin 80 mg, equipotent to the rosuvastatin 20 mg dose used in JUPITER. Primary prevention was the focus and secondary prevention was not modeled explicitly. Quality-adjusted life-years (QALYs) were calculated using nationally representative preference-based utility weights. One-way sensitivity analyses and multivariate probabilistic sensitivity analysis were used to explore uncertainty in model parameters as well as estimate the likelihood of cost-effectiveness when all event rates, costs and utilities were drawn randomly from distributions reflecting uncertainty.

RESULTS

Statin therapy cost $10,889/QALY for vascular event prevention in this population. Results were sensitive to the cost of statin treatment. Based on 10,000 simulations, statin therapy was cost-effective in 99.5% of simulations, using a willingness-to-pay threshold of $20,000/QALY, and 100% of simulations using a threshold of $50,000/QALY.

CONCLUSIONS

Treatment with statins in patients with elevated hs-CRP but normal cholesterol appears to be cost-effective. Limitations of this study include the assumption that an equipotent dose of simvastatin resulted in the same risk reduction as rosuvastatin. Further, post-event states simulated the average experience of a patient. Continued statin use, subsequent events and/or heart failure were not explicitly modeled.

Cost-effectiveness of using high-sensitivity C-reactive protein to identify intermediate- and low-cardiovascular-risk individuals for statin therapy

BACKGROUND

Many myocardial infarctions and strokes occur in individuals with low-density lipoprotein cholesterol levels below recommended treatment thresholds. High sensitivity C-reactive protein (hs-CRP) testing has been advocated to identify low- and intermediate-risk individuals who may benefit from statin therapy.

METHODS AND RESULTS

A decision analytic Markov model was used to follow hypothetical cohorts of individuals with normal lipid levels but without coronary artery disease, peripheral arterial disease, or diabetes mellitus. The model compared current Adult Treatment Panel III practice guidelines, a strategy of hs-CRP screening in those without an indication for statin treatment by current practice guidelines followed by treatment only in those with elevated hs-CRP levels, and a strategy of statin therapy at specified predicted risk thresholds without hs-CRP testing. Risk-based treatment without hs-CRP testing was the most cost-effective strategy, assuming that statins were equally effective regardless of hs-CRP status. However, if normal hs-CRP levels identified a subgroup with little or no benefit from statin therapy (<20% relative risk reduction), then hs-CRP screening would be the optimal strategy. If harms from statin use were greater than generally recognized, then use of current clinical guidelines would be the optimal strategy.

CONCLUSION

Risk-based statin treatment without hs-CRP testing is more cost-effective than hs-CRP screening, assuming that statins have good long-term safety and provide benefits among low-risk people with normal hs-CRP.

Increased C-reactive protein is associated with future development of diabetes mellitus in essential hypertensive patients

Coexistence of hypertension and diabetes mellitus (DM) increases the risk of cardiovascular disease. However, factors associated with future development of DM have not been well elucidated in patients already having essential hypertension. This study prospectively included 168 patients (mean age 41 +/- 7 years, 112 men) with essential hypertension. All patients did not have DM and vascular or renal complications initially. Baseline demographic data, blood pressure, body mass index, and antihypertensive agents were carefully evaluated and serum high-sensitivity C-reactive protein (hsCRP) was measured at the beginning of the study. All of the patients were followed for at least 6 months. The study endpoint was occurrence of new DM. After a mean follow-up period of 32 +/- 10 months, 22 subjects (13.1%) developed new DM. Patients with new DM had higher baseline glucose (105.2 +/- 11.8 vs 94.2 +/- 8.0 mg/dl, P < 0.001), triglyceride level (213.7 +/- 112.4 vs 155.6 +/- 83.2 mg/dl, P = 0.04), log hsCRP (0.31 +/- 0.44 vs 0.19 +/- 0.25 mg/dl, P = 0.016), and lower high-density lipoprotein (40.2 +/- 7.8 vs 46.6 +/- 14.4 mg/dl, P = 0.045). Total cholesterol, low-density lipoprotein, homeostasis model assessment index, and adiponectin were not different in patients with or without new DM. Among antihypertensive agents, only use of beta-blocker was significantly associated with new DM (P = 0.008). Multivariate Cox regression analysis showed log hsCRP (hazard ratio [HR] 9.77, 95% confidence interval [CI] 2.97-32.10, P < 0.001), age (HR 1.21, 95% CI 1.06-1.38, P = 0.004), and baseline glucose level (HR 1.11, 95% CI 1.06-1.15, P < 0.001) to be independent predictors for occurrence of new DM. High-sensitivity CRP was an independent factor for future development of DM in essential hypertensive patients. Increased inflammation might have a key role in the pathogenesis of DM in hypertension.

Relation of baseline high-sensitivity C-reactive protein level to cardiovascular outcomes with rosuvastatin in the Justification for Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER)

In the Justification for Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER), random allocation of rosuvastatin compared to placebo among primary prevention patients with a low-density lipoprotein cholesterol level of <130 mg/dl and a high-sensitivity C-reactive protein (hs-CRP) level of > or =2 mg/L resulted in a highly significant 44% reduction in major vascular events. However, the relation of baseline hs-CRP levels to risk within JUPITER has not previously been described and has been an area of controversy for study interpretation. As reported in the present study for the first time, despite enrolling patients with a constrained range of values, increasing baseline hs-CRP levels within JUPITER were nonetheless associated with increasing vascular risk in analyses treating hs-CRP as a continuous variable, as an ordinal variable, and as a threshold variable. As anticipated, the relative risk reduction associated with rosuvastatin was similar in magnitude across the tertile and threshold levels of entry hs-CRP. In conclusion, as the absolute risk increased with increasing hs-CRP, the absolute risk reduction associated with rosuvastatin within JUPITER was also greatest among those with the greatest entry hs-CRP levels.

Clinical implications of JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) in a U.S. population insights from the ARIC (Atherosclerosis Risk in Communities) study

OBJECTIVES

The purpose of this study is to describe the proportion of "JUPITER-eligible" (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) individuals and clinical outcomes of individuals based on high-sensitivity C-reactive protein (hs-CRP) and low-density lipoprotein cholesterol (LDL-C) strata in the ARIC (Atherosclerosis Risk in Communities) study.

BACKGROUND

Questions remain after the JUPITER study, including whether the observed cardiovascular disease (CVD) event rates would persist with time and how these event rates would compare with other populations (lower hs-CRP and/or higher LDL-C levels).

METHODS

After stratification into 4 groups based on LDL-C and hs-CRP levels, with cutoffs at 130 mg/dl and 2.0 mg/l, respectively, incident CVD events were examined (mean follow-up, 6.9 years) and compared.

RESULTS

Of 8,907 age-eligible participants, 18.2% (n = 1,621) were JUPITER-eligible (hs-CRP > or = 2.0 mg/l, LDL-C <130 mg/dl) and had an absolute CVD risk of approximately 10.9% over a mean follow-up of 6.9 years (1.57% per year). If JUPITER hazard ratios were applied to this group, the number needed to treat to prevent 1 CVD event would be estimated at 38 over 5 years and 26 over 6.9 years.

CONCLUSIONS

ARIC participants with elevated hs-CRP and low LDL-C had a CVD event rate of 1.57% per year over 6.9 years, similar to the CVD event rate noted in the JUPITER study placebo group (1.36% per year over 1.9 years). The association of hs-CRP > or = 2.0 mg/l with increased CVD risk and mortality regardless of LDL-C provides us a simple method of using age and hs-CRP level for identifying higher risk individuals. (Atherosclerosis Risk in Communities study; NCT00005131).

Primary and secondary prevention of cardiovascular disease in older adults: a status report

This article reviews cardiovascular disease (CVD) prevention in older patients, highlighting results from recent clinical studies related to primary and secondary prevention. Many of these studies demonstrated greater absolute reductions in major cardiovascular events among older, higher-risk populations compared with younger patients. Guideline recommendations for CVD risk factor modification are also reviewed with emphasis on issues pertaining to the older adult population.

Comparative Efficacy and Safety of Low-Dose Pitavastatin Versus Atorvastatin in Patients with Hypercholesterolemia

Background:

Previous studies have shown conflicting results on low-density lipoprotein cholesterol (LDL-C) reduction for comparable doses of pitsvastatin and atorvastatin.

Objective:

To compare the efficacy of pitavastatin 1 mg once daily with that of atorvastatin 10 mg once daily on lipoprotein change, safety, and cost per percent LDL-C reduction.

Methods:

An 8-week, randomized, open-label, parallel trial was conducted in patients with hypercholesterolemia. One hundred patients were equally randomized to receive pitavastatin 1 mg once daily or atorvastatin 10 mg once daily; 98 completed the study. Outcomes were assessed at baseline and at the end of the study.

Results:

Pitavastatin lowered LDL-C levels from baseline by 37% compared with 46% in the atorvastatin group (p < 0.001). The reduction of total cholesterol (TC) levels from baseline was significantly different between the pitavastatin (28%) and atorvastatin (32%) groups (p = 0.005). There was no significant difference in the percentage of changes in triglyceride and high-density lipoprotein cholesterol levels between groups. The percentage of patients who achieved LDL-C goals according to National Cholesterol Education Program–Adult Treatment Panel III guidelines was not significantly different between the pitavastatin (74%) and atorvastatin (84%) groups (p = 0.220). In addition, both regimens were well tolerated, with no patient developing an elevation of more than 3 times the upper normal limit of alanine aminotransferase or 10 times that of creatine kinase. The monthly cost per percent LDL-C reduction in the pitavastatin group ($0.77) was about 50% lower than the cost in the atorvastatin ($1.56) group.

Conclusions:

Although pitavastatin 1 mg daily was not as effective at lowering LDL-C and TC levels as atorvastatin 10 mg daily, the number of patients achieving their LDL-C goals with pitavastatin was comparable with the number using atorvastatin. Pitavastatin 1 mg once daily may be an alternative regimen with cost-saving benefits but without a significant decrease in therapeutic benefit or increase in adverse events in patients with hypercholesterolemia.

The JUPITER and AURORA clinical trials for rosuvastatin in special primary prevention populations: perspectives, outcomes, and consequences

Statins have emerged at the forefront of preventive cardiology and have significantly reduced cardiovascular events and mortality. Nonetheless, cardiovascular disease remains the leading cause of death in the United States and in other developed countries, as well as the etiology of significant morbidity and health-care expenditure. In an attempt to reduce potentially missed opportunities for instituting preventive therapy, the JUPITER study (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) and the AURORA study (A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events) examined the effect of statins in two specific patient populations who currently do not meet the guidelines for statin treatment, but nonetheless, are at high cardiovascular risk. This review outlines the JUPITER and AURORA trials, interprets the data and significance of the results, analyses the drawbacks and impact of both trials and delineates the potential for further clinical trials.

Primary prevention of vascular events in patients with high levels of C-reactive protein: the JUPITER study

The Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study was the first large-scale, prospective study to examine the benefits of statin therapy in subjects with elevated levels of high-sensitivity C-reactive protein but with low-to-normal LDL-cholesterol levels, who were not qualified for lipid-lowering treatment according to the current guidelines for primary prevention. The JUPITER study aimed to determine whether rosuvastatin 20 mg daily would reduce the rate of first major cardiovascular events, including cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, hospitalization for unstable angina or arterial revascularization. Rosuvastatin reduced LDL-cholesterol levels by 50% and high-sensitivity C-reactive protein by 37%. Compared with placebo, the combined primary end point was reduced in 44% (p < 0.00001), and total mortality in 20% (p = 0.02). The trial confirmed the relationship between the rates of major cardiovascular events with both high-sensitivity C-reactive protein and LDL-cholesterol levels achieved after statin treatment. Interestingly, this was the first large, prospective statin trial to show benefit in the reduction of venous thromboembolism.

[Prognostic value and clinical effectiveness of high sensitivity C-reactive protein as a marker in primary prevention of major cardiac events]

OBJECTIVE

To compare the predictive value and the clinical effectiveness of additional high sensitivity C-reactive protein (hs-CRP) screening as opposed to traditional risk factor screening alone as a strategy of primary prevention of coronary artery disease (CAD).

METHODS

Following a comprehensive search of 26 electronic databases by DAHTA DIMDI, a systematic review was performed in accordance with international standards of evidence based medicine. Eight publications on risk prediction and one study addressing clinical decision-analytic modelling were included in the assessment.

RESULTS

The adjusted relative risk of a high hs-CRP level (> 3 mg/L) for myocardial infarction, cardiac related death, and cardiovascular events ranged from 0.7 to 2.47 (p < 0.05 in 4 of 7 studies). The area under the receiver operating characteristic curve (AUC) increased by 0.00 to 0.027 when hs-CRP was added to the prediction models (4 of 7 studies statistically significant with p < 0.05). Based on a published decision-analytic model examining hs-CRP screening, the gain in life expectancy due to statin therapy in individuals with elevated hs-CRP was similar when compared to patients with hyperlipidaemia. Nonetheless, evidence on many model parameters was limited.

CONCLUSION

Screening with hs-CRP in addition to traditional risk factors improves risk prediction. However, the incremental effect is moderate and the clinical relevance remains unclear.

Knee osteoarthritis in obese women with cardiometabolic clustering

OBJECTIVE

To assess the role of obesity and metabolic dysfunctionality with knee osteoarthritis (OA), knee joint pain, and physical functioning performance, adjusted for joint space width (JSW) asymmetry.

METHODS

Knee OA was defined as a Kellgren/Lawrence score > or =2 on weight-bearing radiographs. Obesity was defined as a body mass index > or =30 kg/m2. Cardiometabolic clustering classification was based on having > or =2 of the following factors: low levels of high-density lipoprotein cholesterol; elevated levels of low-density lipoprotein cholesterol, triglycerides, blood pressure, C-reactive protein, waist:hip ratio, or glucose; or diabetes mellitus. The difference between lateral and medial knee JSW was used to determine joint space asymmetry.

RESULTS

In a sample of women (n = 482, mean age 47 years), prevalences of knee OA and persistent knee pain were 11% and 30%, respectively. The knee OA prevalence in nonobese women without cardiometabolic clustering was 4.7%, compared with 12.8% in obese women without cardiometabolic clustering and 23.2% in obese women with cardiometabolic clustering. Nonobese women without cardiometabolic clustering were less likely to perceive themselves as limited compared with women in all other obesity/cardiometabolic groups (P < 0.05). Similar associations were seen with knee pain and physical functioning measures. The inclusion of a joint space asymmetry measure was associated with knee OA but not with knee pain or physical functioning.

CONCLUSION

Knee OA was twice as frequent in obese women with cardiometabolic clustering compared with those without, even when considering age and joint asymmetry. Obesity/cardiometabolic clustering was also associated with persistent knee pain and impaired physical functioning.

Primary and secondary prevention of cardiovascular diseases: a practical evidence-based approach

Despite the fact that we possess highly effective tools for the primary and secondary prevention of myocardial infarction and other complications of atherosclerosis, coronary heart disease remains the most common cause of death in our society. Arterial inflammation and endothelial dysfunction play central roles in the pathogenesis of atherosclerosis and adverse cardiovascular (CV) events. Therapeutic lifestyle changes in conjunction with an aggressive multidrug regimen targeted toward the normalization of the major CV risk factors will neutralize the atherogenic milieu, reduce vascular inflammation, and markedly decrease the risk of adverse CV events and need for revascularization procedures. Specific CV risk factors and optimal therapies for primary and secondary prevention are discussed.

Primary and secondary prevention of cardiovascular diseases: a practical evidence-based approach

Despite the fact that we possess highly effective tools for the primary and secondary prevention of myocardial infarction and other complications of atherosclerosis, coronary heart disease remains the most common cause of death in our society. Arterial inflammation and endothelial dysfunction play central roles in the pathogenesis of atherosclerosis and adverse cardiovascular (CV) events. Therapeutic lifestyle changes in conjunction with an aggressive multidrug regimen targeted toward the normalization of the major CV risk factors will neutralize the atherogenic milieu, reduce vascular inflammation, and markedly decrease the risk of adverse CV events and need for revascularization procedures. Specific CV risk factors and optimal therapies for primary and secondary prevention are discussed.