Images in clinical medicine. Caput medusae

If LDL-C is the answer...what was the question? What do the data really show?

The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors are frequently utilized in the treatment of hypercholesterolemia. With recently completed statin clinical cardiovascular outcomes data available, the purpose of this review is to analyze the relative benefits of each molecule and to determine whether "lower is better" is a correct hypothesis for secondary prevention. Twenty-one clinical studies, each with a duration of statin therapy of 6 months or longer, were reviewed, and the pharmacologic effects of these agents on cardiovascular outcomes was examined. As evaluated by study drug, statistical event reduction was achieved in seven of nine pravastatin studies, one of three simvastatin studies, one of six lovastatin studies, zero of two fluvastatin studies, and zero of one atorvastatin study. Pravastatin was the only statin proven statistically to reduce events in both primary and secondary prevention. Thus, all of the statins do not appear to be the same in terms of their ability to reduce cardiovascular events. Until head-to-head trials have been completed, these clinical outcomes data suggest that in patients with severe hypercholesterolemia who require high-dose statin therapy, simvastatin 80 mg each evening would appear to be the agent of choice. However, pravastatin 40 mg daily at bedtime appears to be a unique molecule, with the strongest evidence for event reduction in the majority of patients with moderate hypercholesterolemia with, or who are at risk for, coronary heart disease.