Statin wars: emphasis on potency vs event reduction and safety?

Gender, race and cardiac rehabilitation in the United States: is there a difference in care?

Coronary heart disease is the leading cause of death within the United States, involving both genders and among all races and ethnic populations. Cardiac rehabilitation (CR) has been shown to significantly improve morbidity and mortality, and these benefits extend to individuals of both genders and all ages with coronary heart disease. Despite this, referral and participation rates remain surprisingly low. Furthermore, women and minorities have even lower referral rates than do their male and white counterparts. Over the course of this article, we will review CR referral and participation among women, as well as racial and ethnic minorities in the United States. We will also examine barriers to CR participation among these subgroups.

Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention

Substantial data have established that higher levels of physical activity (PA), participating in exercise training (ET), and higher overall cardiorespiratory fitness (CRF) provide considerable protection in the primary and secondary prevention of coronary heart disease (CHD). This review surveys data from epidemiological and prospective ET studies supporting the favorable impact of PA, ET, and CRF in primary CHD prevention. Clearly, cardiac rehabilitation and ET (CRET) programs have been underutilized for patients with CHD, particularly considering the effect of CRET on CHD risk factors, including CRF, obesity indices, fat distribution, plasma lipids, inflammation, and psychological distress, as well as overall morbidity and mortality. These data strongly support the routine referral of patients with CHD to CRET programs and that patients should be vigorously encouraged to attend CRET following major CHD events.

Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention

Substantial evidence indicates that increased levels of physical activity, exercise training, and overall cardiorespiratory fitness provide protection in primary and secondary coronary heart disease (CHD) prevention. Clearly, cardiac rehabilitation and exercise training (CRET) programs have been greatly underused in patients with CHD. We review the benefits of formal CRET programs on CHD risk factors including exercise capacity, obesity indices, plasma lipids, inflammation, and psychosocial stress as well as overall morbidity and mortality. These data support the fact that patients with CHD, especially after major CHD events, need routine referral to CRET programs; and patients should be vigorously encouraged to attend these valuable programs.

The gravity of JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin)

In the recently published Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study, a large, randomized, placebo-controlled trial, rosuvastatin proved to be safe and remarkably effective in the setting of primary prevention. In patients without coronary heart disease or diabetes, with a baseline low-density lipoprotein cholesterol (LDL-C) level < 130 mg/dL and a C-reactive protein (CRP) > or = 2mg/L, a statin-induced LDL-C reduction of 50% reduced serious cardiac events by about 50%, including in women and the elderly, and also lowered all-cause mortality. The mean on-treatment LDL-C level (55 mg/dL) in the rosuvastatin arm of JUPITER was about in the mid-range of the physiologically normal levels. C-reactive protein screening should be considered, especially in patients without preexisting indications for statin therapy. In general, the CRP-lowering efficacy of statin therapy is directly and significantly correlated with its LDL-C-lowering activity. Simvastatin, at the 80-mg daily dose, is more toxic to muscles and liver than other statins at their highest dose, and thus should be used with caution.

Impact of ezetimibe on atherosclerosis: is the jury still out?

Ezetimibe is a new lipid-lowering agent that inhibits intestinal absorption of dietary cholesterol. It substantially lowers low-density lipoprotein cholesterol levels when used alone or in combination with statins. However, its effect on cardiovascular mortality remains unknown. We reviewed peer-reviewed published literature on the effect of ezetimibe on different phases of atherosclerosis. MEDLINE, EMBASE, BIOSIS, and other Web of Knowledge databases were searched for relevant abstracts and articles published in the English language that compared ezetimibe and statins as modulators of atherosclerosis. On the basis of the available evidence, ezetimibe appears to reduce inflammation when used in combination with statins, but its effect on endothelial function is mixed and less clear. The effect of ezetimibe on coronary disease progression or prevention of cardiovascular events is currently unknown. Use of ezetimibe as a second- or third-line agent to achieve low-density lipoprotein cholesterol treatment goals seems appropriate on the basis of the available evidence.