A comparison of low versus standard dose pravastatin therapy for the prevention of cardiovascular events in the elderly: the pravastatin anti-atherosclerosis trial in the elderly (PATE)

Dataset dependency of low-density lipoprotein-cholesterol estimation by machine learning

OBJECTIVES

We evaluated the applicability of a machine learning-based low-density lipoprotein-cholesterol (LDL-C) estimation method and the influence of the characteristics of the training datasets.

METHODS

Three training datasets were chosen from training datasets: health check-up participants at the Resource Center for Health Science (N = 2664), clinical patients at Gifu University Hospital (N = 7409), and clinical patients at Fujita Health University Hospital (N = 14,842). Nine different machine learning models were constructed through hyperparameter tuning and 10-fold cross-validation. Another test dataset of another 3711 clinical patients at Fujita Health University Hospital was selected as the test set used for comparing and validating the model against the Friedewald formula and the Martin method.

RESULTS

The coefficients of determination of the models trained on the health check-up dataset produced coefficients of determination that were equal to or inferior to those of the Martin method. In contrast, the coefficients of determination of several models trained on clinical patients exceeded those of the Martin method. The means of the differences and the convergences to the direct method were higher for the models trained on the clinical patients' dataset than for those trained on the health check-up participants' dataset. The models trained on the latter dataset tended to overestimate the 2019 ESC/EAS Guideline for LDL-cholesterol classification.

CONCLUSION

Although machine learning models provide valuable method for LDL-C estimates, they should be trained on datasets with matched characteristics. The versatility of machine learning methods is another important consideration.

Efficacy, safety and clinical outcome associated with statin use for primary prevention in Korean patients with low-density lipoprotein cholesterol level ≥ 190 mg/dL: A retrospective cohort study

BACKGROUND

Although the current guideline recommends the use of high-intensity statin to reduce the low-density lipoprotein cholesterol (LDL-C) level by 50% in patients with baseline value of ≥ 190 mg/dL, direct application of this recommendation to Asian populations is still questionable. This study was performed to investigate the statin response of LDL-C in Korean patients with LDL-C ≥ 190 mg/dL.

METHODS

A total of 1,075 Korean patients (age 60.7 ± 12.2 years, women 68%) with baseline LDL-C ≥ 190 mg/dL without cardiovascular disease was retrospectively reviewed. Lipid profiles at 6 months, side effects and clinical outcomes during the follow-up period after statin treatment were assessed according to statin intensity.

RESULTS

Most of the patients (76.3%) were treated with moderate-intensity statins, 11.4% with high-intensity statins, and 12.3% with a statin + ezetimibe. The reductions in LDL-C percentage at 6 months were 48.0%, 56.0% and 53.3% in patients treated with moderate-intensity statins, high-intensity statins and statin + ezetimibe, respectively (P < 0.001). Side effects requiring dose reduction, medication switch or drug interruption were observed in 1.3%, 4.9% and 2.3% of patients treated with moderate-intensity statin, high-intensity statin and statin + ezetimibe, respectively (P = 0.024). During the median follow-duration of 815 days (interquartile range, 408-1,361 days), the incidences of cardiovascular events were not different among the 3 groups (log-rank P = 0.823).

CONCLUSIONS

Compared to high-intensity statin, moderate-intensity statin was effective enough in reaching target goal of LDL-C without increase in cardiovascular risk and with fewer side effects in Korean patients with LDL-C ≥ 190 mg/dL.

Extent of Low-density Lipoprotein Cholesterol Reduction and All-cause and Cardiovascular Mortality Benefit: A Systematic Review and Meta-analysis

ABSTRACT

Lipid-modifying agents steadily lower low-density lipoprotein cholesterol (LDL-C) levels with the aim of reducing mortality. A systematic review and meta-analysis were conducted to determine whether all-cause or cardiovascular (CV) mortality effect size for lipid-lowering therapy varied according to the magnitude of LDL-C reduction. Electronic databases were searched, including PubMed and ClinicalTrials.gov , from inception to December 31, 2019. Eligible studies included randomized controlled trials that compared lipid-modifying agents (statins, ezetimibe, and PCSK-9 inhibitors) versus placebo, standard or usual care or intensive versus less-intensive LDL-C-lowering therapy in adults, with or without known history of CV disease with a follow-up of at least 52 weeks. All-cause and CV mortality as primary end points, myocardial infarction, stroke, and non-CV death as secondary end points. Absolute risk differences [ARD (ARDs) expressed as incident events per 1000 person-years], number needed to treat (NNT), and rate ratios (RR) were assessed. Sixty randomized controlled trials totaling 323,950 participants were included. Compared with placebo, usual care or less-intensive therapy, active or more potent lipid-lowering therapy reduced the risk of all-cause death [ARD -1.33 (-1.89 to -0.76); NNT 754 (529-1309); RR 0.92 (0.89-0.96)]. Intensive LDL-C percent lowering was not associated with further reductions in all-cause mortality [ARD -0.27 (-1.24 to 0.71); RR 1.00 (0.94-1.06)]. Intensive LDL-C percent lowering did not further reduce CV mortality [ARD -0.28 (-0.83 to 0.38); RR 1.02 (0.94-1.09)]. Our findings indicate that risk reduction varies across subgroups and that overall NNTs are high. Identifying patient subgroups who benefit the most from LDL-C levels reduction is clinically relevant and necessary.

A randomized, open-label, parallel, multi-center Phase IV study to compare the efficacy and safety of atorvastatin 10 and 20 mg in high-risk Asian patients with hypercholesterolemia

Background

Although accumulating evidence suggests a more extensive reduction of low-density lipoprotein cholesterol (LDL-C), it is unclear whether a higher statin dose is more effective and cost-effective in the Asian population. This study compared the efficacy, safety, and cost-effectiveness of atorvastatin 20 and 10 mg in high-risk Asian patients with hypercholesterolemia.

Methods

A 12-week, open-label, parallel, multicenter, Phase IV randomized controlled trial was conducted at ten hospitals in the Republic of Korea between October 2017 and May 2019. High-risk patients with hypercholesterolemia, defined according to 2015 Korean guidelines for dyslipidemia management, were eligible to participate. We randomly assigned 250 patients at risk of atherosclerotic cardiovascular disease to receive 20 mg (n = 124) or 10 mg (n = 126) of atorvastatin. The primary endpoint was the difference in the mean percentage change in LDL-C levels from baseline after 12 weeks. Cost-effectiveness was measured as an exploratory endpoint.

Results

LDL-C levels were reduced more significantly by atorvastatin 20 mg than by 10 mg after 12 weeks (42.4% vs. 33.5%, p < 0.0001). Significantly more patients achieved target LDL-C levels (<100 mg/dL for high-risk patients, <70 mg/dL for very high-risk patients) with atorvastatin 20 mg than with 10 mg (40.3% vs. 25.6%, p < 0.05). Apolipoprotein B decreased significantly with atorvastatin 20mg versus 10 mg (−36.2% vs. −29.9%, p < 0.05). Lipid ratios also showed greater improvement with atorvastatin 20 mg than with 10 mg (total cholesterol/high-density lipoprotein cholesterol ratio, −33.3% vs. −29.4%, p < 0.05; apolipoprotein B/apolipoprotein A1 ratio, −36.7% vs. −31.4%, p < 0.05). Atorvastatin 20 mg was more cost-effective than atorvastatin 10 mg in terms of both the average and incremental cost-effectiveness ratios. Safety and tolerability of atorvastatin 20 mg were comparable to those of atorvastatin 10 mg.

Conclusion

In high-risk Asian patients with hypercholesterolemia, atorvastatin 20 mg was both efficacious in reducing LDL-C and cost-effective compared with atorvastatin 10 mg.

Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic Cardiovascular Disease in 75 or Older (EWTOPIA 75)

Background:

Evidence regarding the primary prevention of coronary artery disease events by low-density lipoprotein cholesterol (LDL-C) lowering therapy in older individuals, aged ≥75 years, is insufficient. This trial tested whether LDL-C–lowering therapy with ezetimibe is useful for the primary prevention of cardiovascular events in older patients.

Methods:

This multicenter, prospective, randomized, open-label, blinded end-point evaluation conducted at 363 medical institutions in Japan examined the preventive efficacy of ezetimibe for patients aged ≥75 years, with elevated LDL-C without history of coronary artery disease. Patients, who all received dietary counseling, were randomly assigned (1:1) to receive ezetimibe (10 mg once daily) versus usual care with randomization stratified by site, age, sex, and baseline LDL-C. The primary outcome was a composite of sudden cardiac death, myocardial infarction, coronary revascularization, or stroke.

Results:

Overall, 3796 patients were enrolled between May 2009 and December 2014, and 1898 each were randomly assigned to ezetimibe versus control. Median follow-up was 4.1 years. After exclusion of 182 ezetimibe patients and 203 control patients because of lack of appropriate informed consent and other protocol violations, 1716 (90.4%) and 1695 (89.3%) patients were included in the primary analysis, respectively. Ezetimibe reduced the incidence of the primary outcome (hazard ratio [HR], 0.66; 95% CI, 0.50–0.86; P =0.002). Regarding the secondary outcomes, the incidences of composite cardiac events (HR, 0.60; 95% CI, 0.37–0.98; P =0.039) and coronary revascularization (HR, 0.38; 95% CI, 0.18–0.79; P =0.007) were lower in the ezetimibe group than in the control group; however, there was no difference in the incidence of stroke, all-cause mortality, or adverse events between trial groups.

Conclusions:

LDL-C–lowering therapy with ezetimibe prevented cardiovascular events, suggesting the importance of LDL-C lowering for primary prevention in individuals aged ≥75 years with elevated LDL-C. Given the open-label nature of the trial, its premature termination and issues with follow-up, the magnitude of benefit observed should be interpreted with caution.

Clinical Registration:

URL: https://www.umin.ac.jp . Unique identifier: UMIN000001988.

Lipid Lowering Therapy, Low-Density Lipoprotein Level and Risk of Intracerebral Hemorrhage - A Meta-Analysis

BACKGROUND

The association of lipid lowering therapy and intracerebral hemorrhage risk is controversial.

METHODS

We performed a cumulative meta-analysis of lipid lowering trials that reported intracerebral hemorrhage. Statin, fibrate, ezetimibe, PCSK9, and CETP trials were included. We explored whether the association of lipid lowering therapy and risk of intracerebral hemorrhage may vary by baseline low-density lipoprotein (LDL) level, mean change in LDL or baseline cardiovascular risk of population.

RESULTS

Among 39 trials (287,651 participants), lipid lowering therapy was not associated with a statistically significant increased risk of intracerebral hemorrhage (ICH) in primary and secondary prevention trials combined (odds ratio [OR], 1.12; 95% confidence interval [CI], .98-1.28). Lipid lowering was associated with an increased risk of ICH in secondary prevention trials (OR, 1.18; 95% CI, 1.00-1.38), but not in primary prevention trials (OR, 1.01; 95% CI, .78-1.30), but the test for interaction was not significant (P for interaction = .31). Meta-regression of baseline LDL or difference in LDL reduction between active and control did not explain significant heterogeneity between studies for ICH risk. Of 1000 individuals treated for 1 year for secondary prevention, we estimated 9.17 (95% CI, 5.78-12.66) fewer ischemic strokes and .48 (95% CI, .06-1.02) more ICH, and a net reduction of 8.69 in all stroke per 1000 person-years.

CONCLUSIONS

The benefits of lipid lowering therapy in prevention of ischemic stroke greatly exceed the risk of ICH. Concern about ICH should not discourage stroke clinicians from prescribing lipid lowering therapy for secondary prevention of ischemic stroke.

Effects of sarpogrelate, eicosapentaenoic acid and pitavastatin on arterioslcerosis obliterans-related biomarkers in patients with type 2 diabetes (SAREPITASO study)

BACKGROUND

The aim was to evaluate the significance of arteriosclerosis obliterans-related biomarkers in patients with type 2 diabetes mellitus (T2DM), and to compare the effects of sarpogrelate, eicosapentaenoic acid (EPA) and pitavastatin on these markers.

PATIENTS AND METHODS

Seventy-two arteriosclerosis obliterans patients with T2DM were classified into two groups, pitavastatin with either sarpogrelate (PS) or EPA (PE). We observed no differences in all biomarkers between the PS and PE groups before treatments.

RESULTS

The levels of body mass index, hemoglobin A1c, soluble E-selectin, soluble vascular cell adhesion molecule 1, plasminogen activator inhibitor-1 and platelet-derived microparticle in the PE group decreased significantly after treatment. The ankle branchial pressure index and adiponectin levels significantly increased in the PE group after treatment compared with the PS group.

CONCLUSION

These results suggest that combination therapy using pitavastatin and EPA possesses an antiatherosclerotic effect and may be beneficial for prevention of vascular complications in patients with T2DM.

Treatment patterns in hyperlipidaemia patients based on administrative claim databases in Japan

BACKGROUND AND AIMS

Real-world evidence on treatment of hyperlipidaemia (HLD) in Japan is limited. We aimed to describe treatment patterns, persistence with, and adherence to treatment in Japanese patients with HLD.

METHODS

Retrospective analyses of adult HLD patients receiving drug therapy in 2014-2015 were conducted using the Japan Medical Data Center (JMDC) and Medical Data Vision (MDV) databases. Depending on their HLD treatment history, individuals were categorised as untreated (UT) or previously treated (PT), and were followed for at least 12 months. Outcomes of interest included prescribing patterns of HLD drug classes, persistence with treatment at 12 months, and adherence to treatment.

RESULTS

Data for 49,582 and 53,865 patients from the JMDC and MDV databases, respectively, were analysed. First-line HLD prescriptions for UT patients were predominantly for moderate statins (JMDC: 75.9%, MDV: 77.0%). PT patients most commonly received combination therapy (JMDC: 43.9%, MDV: 52.6%). Approximately half of the UT patients discontinued treatment during observation. Within each cohort, persistence rates were lower in UT patients than in PT patients (JMDC: 45.0% vs. 77.5%; MDV: 51.9% vs. 85.3%). Adherence was ≥80% across almost all HLD drug classes, and was slightly lower in the JMDC cohort than MDV cohort.

CONCLUSIONS

Most common prescriptions were moderate statins in UT patients and combination therapy in PT patients. The high discontinuation rate of HLD therapy in UT patients warrants further investigation and identification of methods to encourage and support long-term persistence.

LDL-cholesterol goal attainment under persistent lipid-lowering therapy in northeast China: Subgroup analysis of the dyslipidemia international study of China (DYSIS-China)

Lipid-lowering therapy with statins reduces the risk of cardiovascular events, but the efficacy of persistent treatment in a real-world setting may vary from regions. Routine lipid-lowering therapy in the region with a high prevalence of cardiovascular disease may lead to more failures of goal attainment. We therefore performed a study to observe different lipid-lowering strategies in northeast (NE) China with respect to low-density lipoprotein-cholesterol (LDL-C) reduction and goal attainments.A cross-sectional study (DYSIS-China) was conducted in 2012, involving 25,317 patients from 122 centers across China who were diagnosed with hyperlipidemia and treated with lipid-lowering therapy for at least 3 months. Of these patients, 4559 (18.0%) were assigned to the NE group according to their residential zones.Patients in the NE group tended to be younger, female, overweight, and had more comorbidities and higher blood lipid levels than those in the non-NE group (P < .001). The goal attainment for LDL-C in NE was lower than non-NE (45.3% vs 65.1%, P < .001), and especially lower in high (NE vs non-NE, 38.5% vs 58.6%) and very high (NE vs non-NE, 22.6% vs 43.7%) risk patients. The proportion of high intensity statin was lower in NE than non-NE, and the proportion of combination therapy was similar (∼2%). However, the goal attainment did not increase after administering higher dosages of statins in 2 groups. Logistic regression analysis identified diabetes mellitus (DM), coronary heart disease (CHD), cerebrovascular disease (CBD), being female, body mass index (BMI) >24 kg/m, drinking alcohol, smoking, and being residence in NE China as independent predictors of LDL-C attainment.Despite having received persistent lipid-lowering treatments, the current situation of dyslipidemia patients in NE China is unsatisfactory. The main treatment gap might be related to the choice of statin and effective combination therapy and the control of comorbidities and obesity, especially for high-risk patients.

Use of Moderate-Intensity Statins for Low-Density Lipoprotein Cholesterol Level above 190 mg/dL at Baseline in Koreans

The ACC/AHA 2013 guideline recommends high-intensity statin therapy for a decrease in low-density lipoprotein cholesterol (LDL-C) level by >50% among patients with baseline values of ≥190 mg/dL (approximately 4.872 mmol/L); however, this value should be modified before applying it to Korean populations. We investigated the statin-specific LDL-C-lowering effects in Korean patients with baseline LDL-C value ≥4.872 mmol/L. Data of patients prescribed a statin for the first time from January 2009 to December 2013 were assessed. In patients with baseline LDL-C value ≥4.872 mmol/L, laboratory data for a maximum of 6 months from the date of first statin prescription were collected. Among 33,721 patients who were prescribed a statin for the first time, 655 patients had a baseline LDL-C value ≥4.872 mmol/L (1.9%). Of these, 179 patients were analysed. Patients receiving moderate-intensity statins were divided into two groups based on LDL-C reduction rate (p = 0.0002), defined as moderate-high-intensity (atorvastatin 20 mg, rosuvastatin 10 mg, simvastatin 20 mg) and moderate-low-intensity (atorvastatin 10 mg, pitavastatin 2 mg, pravastatin 40 mg) statin groups. LDL-C reduction rates did not significantly differ between the moderate-high- and high-intensity statin groups (p = 0.4895). We found that some moderate-intensity statins demonstrated a LDL-C-lowering effect of more than 50% in Korean patients with a baseline LDL-C value ≥4.872 mmol/L. Our results reflect the need of a large-scale, randomized, controlled trial on partial reclassification of statins for patients with baseline LDL-C value ≥4.872 mmol/L before adopting ACC/AHC guidelines in Korea.

Preventive effect of pravastatin on the development of hypertension in patients with hypercholesterolemia: A post-hoc analysis of the Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA) Study

BACKGROUND

It remains unclear whether treatment of dyslipidemia with 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins) reduces the risk of developing hypertension.

OBJECTIVE

In this post-hoc analysis of the Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA) Study, a large-scale primary prevention trial with pravastatin, we examined the preventive effect of pravastatin on the future development of hypertension in patients with hypercholesterolemia.

METHODS

Of the overall (MEGA) Study population, 3397 nonhypertensive patients at baseline were enrolled in this study. The patients were randomly assigned to either the diet alone group (n = 1722) or the diet plus pravastatin group (n = 1675) and then were followed-up for a median of 36 months to determine new-onset hypertension.

RESULTS

During the follow-up period, 1595 patients developed hypertension (49.1% in the diet alone group and 44.7% in the diet plus pravastatin group). After adjusting for multiple covariates, the diet plus pravastatin group showed a 10% reduction in the risk of developing hypertension (hazard ratio 0.90, 95% confidence interval 0.81-0.998), compared with the diet alone group. Subgroup analyses revealed that the preventive effect of pravastatin on the development of hypertension was pronounced in patients aged ≥60 years, men, those with chronic kidney disease or diabetes mellitus and those without obesity.

CONCLUSIONS

Pravastatin reduced the risk of developing hypertension in Japanese patients with hypercholesterolemia. The risk reduction of cardiovascular disease with statins could be partly explained by their preventive effect on the development of hypertension.

Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials

BACKGROUND AND PURPOSE

Statin therapy decreases the risk of ischemic stroke. An increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue, we performed a meta-analysis of randomized controlled trials using statins that reported ICH.

METHODS

We performed a literature search of Medline, Web of Science, and The Cochrane Library through January 25, 2012, and identified additional randomized controlled trials by reviewing reference lists of retrieved studies and prior meta-analyses. All randomized controlled trials of statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. Thirty-one randomized controlled trials were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses.

RESULTS

A total of 91,588 subjects were included in the active group and 91,215 in the control group. There was no significant difference in incidence of ICH observed in the active treatment group versus control (OR, 1.08; 95% CI, 0.88-1.32; P=0.47). ICH risk was not related to the degree of low-density lipoprotein reduction or achieved low-density lipoprotein cholesterol. Total stroke (OR, 0.84; 95% CI, 0.78-0.91; P<0.0001) and all-cause mortality (OR, 0.92; CI, 0.87-0.96; P=0.0007) were significantly reduced in the active therapy group. There was no evidence of publication bias.

CONCLUSIONS

Active statin therapy was not associated with significant increase in ICH in this meta-analysis of 31 randomized controlled trials of statin therapy. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.

"Just make it lower" is an alternative strategy of lipid-lowering therapy with statins in Japanese patients: LDL-cholesterol: the lower, the better; is it true for Asians? (Con)

It is well known that statins improve the prognosis of cardiovascular diseases (CVD). Recent randomized control trials (RCTs) of statins conducted in Western countries revealed greater avoidance of cardiovascular events if low-density-lipoprotein cholesterol (LDL-C) reached lower levels. However, it is obvious that this evidence cannot be unconditionally extrapolated to Asians because there are great differences between Japanese and Caucasians in the absolute onset rate of CVD. Results of RCTs with Japanese for primary or secondary prevention of cardiovascular events indicate that we could benefit from statins with a relatively higher target LDL-C as compared with Western populations. In this situation, not only strong but also standard statins are still advantageous and the so-called pleiotropic effects of the drugs come to the fore. In this review, we first discuss differences in the absolute event rate in different populations, and then the lack of evidence for recommended LDL-C treatment targets, particularly in Japanese, although there is reliable evidence for reductions in plaque volume in coronary arteries from RCTs recently conducted in Japan with aggressive lipid-lowering therapy with strong statins. Finally, based on recent data, we propose a new concept regarding the secondary prevention of CVD for current Japanese populations.

Rationale and design of China intensive lipid lowering with statins in acute coronary syndrome: the CHILLAS study

BACKGROUND

Current guidelines recommended intensive low-density lipoprotein cholesterol lowering with statins, aiming at the target of 70 mg/dL (1.81 mmol/L) of low-density lipoprotein cholesterol for those with very high risk of coronary artery events. However, there is no multicenter study assessing the effect of intensive lipid lowering therapy with statins on acute coronary syndrome (ACS) in Chinese population.

METHODS

An open-label multicenter study is planned to evaluate whether intensive treatment with statins for 2 to 5 years results in more reduction of cardiovascular events in patients with ACS compared to the standard statin therapy. A total of 1,600 patients will be randomly assigned to receive intensive statin therapy (atorvastatin, 20 or 40 mg/d, or equivalent dose of other statins) or standard statin therapy (atorvastatin, 10 mg/d, or equivalent dose of other statins). Both groups will receive dietary counseling. Over the follow-up period, the primary outcome measure is the time to occurrence of cardiac death, nonfatal acute myocardial infarction, revascularization with either percutaneous coronary intervention or coronary-artery bypass grafting, documented unstable angina or severe heart failure requiring emergency hospitalization, and stroke. The planned duration for enrollment is between December 2006 and December 2009.

CONCLUSIONS

The CHILLAS study will be the first multicenter study in a Chinese population using a patient-level analysis to compare the effects and safety of intensive statin therapy with that of standard-dose statin therapy, which may provide new evidence and therapeutic standards for the treatment of ACS.

Cardiovascular benefit of magnitude of low-density lipoprotein cholesterol reduction: a comparison of subgroups by age

BACKGROUND

We examined the effect of the magnitude of low-density lipoprotein cholesterol (LDL-C) reduction across subjects of various ages in a retrospective cohort study.

METHODS AND RESULTS

We selected 20,132 male veterans at high risk for an acute cardiovascular event and who had 2 or more LDL-C measurements before their first documented acute myocardial infarction, revascularization, death, or censoring date. LDL-C reduction was categorized as no reduction (<10 mg/dL; reference), small reduction (between 10 and 40 mg/dL), moderate reduction (between 40 and 70 mg/dL), or large reduction (> or =70 mg/dL). The primary outcome was combined acute myocardial infarction or revascularization. The first and last LDL-C levels in the databases were used to calculate the LDL-C reduction in patients who experienced no outcome or who died. Within each age quartile and in a subgroup of patients > or =80 years of age, a Cox proportional hazards model was used to determine hazard ratios for each category of LDL-C reduction compared with the reference category, with adjustment for age, body mass index, current smoking status, medications, and comorbidities. In all age groups, the magnitude of LDL-C reduction was proportional to the magnitude of cardiovascular risk reduction. Risk reduction for the combined outcome in patients who achieved a large LDL-C reduction was similar in all age quartiles, with multivariate-adjusted hazard ratios of approximately 0.30.

CONCLUSIONS

In a cohort of veterans at high risk for cardiovascular events, patients of all ages, including those 80 years or older, benefitted the most from large reductions in LDL-C.

Lipid-lowering for peripheral arterial disease of the lower limb

BACKGROUND

Lipid-lowering therapy is recommended for secondary prevention in people with coronary artery disease. It may also reduce cardiovascular events and/or local disease progression in people with lower limb peripheral arterial disease (PAD).

OBJECTIVES

To assess the effects of lipid-lowering therapy on all-cause mortality, cardiovascular events and local disease progression in patients with PAD of the lower limb.

SEARCH STRATEGY

The authors searched The Cochrane Peripheral Vascular Diseases Group's Specialised Register (last searched February 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2007) for publications describing randomised controlled trials of lipid-lowering therapy in peripheral arterial disease of the lower limb.

SELECTION CRITERIA

Randomised controlled trials of lipid-lowering therapy in patients with PAD of the lower limb.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data.

MAIN RESULTS

Eighteen trials were included, involving a total of 10,049 participants. Trials differed considerably in their inclusion criteria, outcomes measured, and type of lipid-lowering therapy used. Only one trial (PQRST) reported a detrimental effect of active treatment on blood lipid/lipoprotein levels. The pooled results from all eligible trials indicated that lipid-lowering therapy had no statistically significant effect on overall mortality (Odds Ratio (OR) 0.86; 95% Confidence Interval (CI) 0.49 to 1.50) or on total cardiovascular events (OR 0.8; 95% CI 0.59 to 1.09). However, subgroup analysis which excluded PQRST showed that lipid-lowering therapy significantly reduced the risk of total cardiovascular events (OR 0.74; CI 0.55 to 0.98). This was primarily due to a positive effect on total coronary events (OR 0.76; 95% CI 0.67 to 0.87). Greatest evidence of effectiveness came from the use of simvastatin in people with a blood cholesterol >/= 3.5 mmol/litre (HPS). Pooling of the results from several small trials on a range of different lipid-lowering agents indicated an improvement in total walking distance (Weighted Mean Difference (WMD) 152 m; 95% CI 32.11 to 271.88) and pain-free walking distance (WMD 89.76 m; 95% CI 30.05 to 149.47) but no significant impact on ankle brachial index (WMD 0.04; 95% CI -0.01 to 0.09).

AUTHORS' CONCLUSIONS

Lipid-lowering therapy is effective in reducing cardiovascular mortality and morbidity in people with PAD. It may also improve local symptoms. Until further evidence on the relative effectiveness of different lipid-lowering agents is available, use of a statin in people with PAD and a blood cholesterol level >/=3.5 mmol/litre is most indicated.

Normal mortality in the elderly with diabetes under strict glycemic and blood pressure control: outcome of 6-year prospective study

Mortality, macroangiopathic events and end-stage renal disease (ESRD) in the elderly under long-term, intensive multifactorial diabetes control were prospectively investigated. Three hundred and eighty-eight elderly patients (> or =65 years) with type 2 diabetes (the mean age 72.9 years, men/women ratio 176/212) were followed-up for 6 years with HbA1c 7.0%, BP 145/80 mmHg and total cholesterol<240 mg/dl as targets. The mean baseline HbA1c was 6.8%, BP 137/74 mmHg and total cholesterol 196 mg/dl, and corresponding values upon closing 6.9%, 134/72 mmHg and 188 mg/dl respectively. Mortality rate was 19.6%/6 years (1.01 times that of age- and sex-matched general population), and macroangiopathic events developed in 142 (36.6%) and ESRD in 9 (2.3%). Independent risk factors: low glomerular filtration rate (GFR) (P<0.001), prior stroke (P=0.002), age (P=0.001) and DeltaBMI (P=0.001) for mortality; prior stroke (P<0.001) and coronary events (P=0.042), high LDL-cholesterol (P=0.004), low GFR (P=0.028), and past maximum BMI (P=0.032) and age (P=0.019) for macroangiopathy; low GFR (P<0.001) for ESRD. No smoking was an independent protective factor for mortality (P=0.008). In conclusion, normal mortality was attained in the elderly under intensive mutifactorial diabetes control. Renal dysfunction, prior stroke, high LDL-cholesterol, and prior obesity were prominent risks for mortality, macroangiopathy and/or ESRD.

Statins for the primary prevention of cardiovascular events in older adults: a review of the evidence

BACKGROUND

Although statins have been demonstrated to be beneficial for secondary prevention in the elderly, their use for primary prevention has not been well described.

OBJECTIVE

In this review, we summarize data regarding the efficacy, safety, and current recommendations for statins for the primary prevention of cardiovascular events in older adults.

METHODS

This review is based on a computerized literature search of the PubMed database for articles published in the English language from January 1980 to June 2006. Key words searched individually and cross-referenced included: statins, HMG-CoA reductase inhibitors, cholesterol, elderly, aged, cardiovascular disease, primary prevention, risk stratification, and C-reactive protein. This search produced 445 citations; reference lists revealed an additional 12 citations, all of which were screened for relevance to the topic.

RESULTS

The existing evidence suggests, but does not confirm, benefit from the use of statins for primary prevention in the elderly subgroup (ie, those aged >65 years). Of the 6 published trials of statins for primary prevention, only 3 included subjects aged >75 years, and subgroup results in older adults are unavailable. Current guidelines recommend statins for individuals based on their assessed cardiovascular risk.

CONCLUSIONS

Extension of treatment guidelines should consider an individual's global risk of coronary heart disease. However, due to the prevalence of subclinical disease in older adults, risk may be higher or otherwise differ with age. In addition, tolerance for and barriers to adherence with long-term medical therapy are important treatment considerations in older adults. Prospective, randomized controlled trials that better define the tolerability, safety, and efficacy of statin therapy in older adults with elevated cholesterol levels and intermediate cardiovascular risk are needed.

Safety and efficacy of statins in Asians

Asian patients frequently have heightened responses to therapeutic drugs. As a consequence, the recommended drug doses are often lower in Asian countries than in Western countries. This practice extends to the use of cardiovascular drugs, including statins for the treatment of dyslipidemia. Pharmacokinetic investigations have noted higher plasma levels of statins in Asians compared with Caucasians, although postmarketing data for all statins have not identified any particular safety issues, even when statins are given at equivalent doses. The potential mechanisms of heightened response to statins in Asians are related to genetically based differences in the metabolism of statins at the level of hepatic enzymes and drug transporters. Studies indicate that lower statin doses achieve lipid improvements in Asian patients comparable with those observed with higher doses in Caucasians. In conclusion, prescribing lower starting doses of statins in Asians appears warranted while research on this subject continues.

Statins: beneficial or adverse for glucose metabolism

Large-scale clinical trials have established that statin use for lowering blood cholesterol is beneficial in reducing atherosclerotic cardiovascular diseases in different populations. However, the general reputation of statins seems to be clouded by a potential adverse effect of a class of statins on glucose metabolism. This paper reviewed clinical data of statins regarding the effects on diabetes mellitus and glucose metabolism. At least five randomized controlled studies, primarily investigating the protective effect of statins on the risk of cardiovascular diseases, have addressed the effect of statins on glucose metabolism in Western countries. One study showed that pravastatin (40 mg/day) was protective against the development of diabetes mellitus. Two studies of atorvastatin (10 mg/day) and one study of simvastatin (40 mg/day) showed no measurable effect of these regimens on the risk of diabetes mellitus or the clinical course of diabetes mellitus. One study of atorvastatin (80 mg/day) versus pravastatin (40 mg/day) suggested a deterioration of glucose metabolism associated with a high dose of atorvastatin. In Japan, a few case reports have noted a potential adverse effect of atorvastatin on glycemic control in patients with diabetes mellitus; however, seven clinical trials have showed no such effect of atorvastatin although these studies were relatively small in size and short in follow-up. Only one of the two observational studies suggested a possible adverse effect of atorvastatin on glycemic control. Evidence is extremely limited regarding atorvastatin use and deterioration in glycemic control, and further studies are needed to draw a conclusion on this issue.

Pravastatin use and the five-year incidence of cancer in coronary heart disease patients: from the prevention of coronary sclerosis study

BACKGROUND

Although the short-term safety of statins is well established, their potential carcinogenicity in the long term is still being debated. The aim of this study was to investigate the association between statin-therapy and the incidence of cancer in coronary heart disease patients.

METHODS

The subjects were 263 patients with coronary heart disease who were from Osaka prefecture and who were admitted to the Osaka Medical Center for Cancer and Cardiovascular Diseases between September 28, 1991 and March 31, 1995. The five-year cancer incidence among the subjects was checked using the database of the institution-based cancer registry of the hospital as well as the population-based Osaka Cancer Registry. The Cox's proportional hazards ratios (HRs) of all cancer incidence and observed/expected (O/E) ratios by cancer site were calculated.

RESULTS

Cancer incidence was observed in 17 patients during the follow-up period. Age (HR=1.16 per one year of age) and continuous smoking during the period (HR=5.82 compared to not smoking during the period) were significantly associated with cancer incidence using multivariable analysis. After being adjusted for sex, age, total serum cholesterol level and smoking habit, the HR of cancer incidence with pravastatin use was 0.78 (95% confidence interval: 0.18-3.46). In the O/E analysis, significantly elevated risks were found for bladder cancer in all the subjects (HR=8.93), as well as in the pravastatin use patients (HR=13.76).

CONCLUSIONS

Pravastatin use for 5 years did not indicate an increase in over all cancer risk.

Influences of age, sex, and LDL-C change on cardiovascular risk reduction with pravastatin treatment in elderly Japanese patients: A post hoc analysis of data from the Pravastatin Anti-atherosclerosis Trial in the Elderly (PATE)

BACKGROUND

The Pravastatin Anti-atherosclerosis Trial in the Elderly (PATE) found that the prevalence of cardiovascular events (CVEs) was significantly lower with standard-dose (10-20 mg/d) pravastatin treatment compared with low-dose (5 mg/d) pravastatin treatment in elderly (aged ⩾ 60 years) Japanese patients with hypercholesterolemia. Small differences in on-treatment total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels between the 2 dose groups in the PATE study were associated with significant differences in CVE prevalence. However, the reasons for these differences have not been determined. How sex and age differences influence the effectiveness of pravastatin also remains unclear.

OBJECTIVES

The aims of this study were to determine the relationship between reduction in LDL-C level and CVE risk reduction in the PATE study and to assess the effects of sex and age on the effectiveness of pravastatin treatment (assessed using CVE risk reduction).

METHODS

In this post hoc analysis, Cox regression analysis was performed to study the relationship between on-treatment (pravastatin 5-20 mg/d) LDL-C level and CVE risk reduction using age, sex, smoking status, presence of diabetes mellitus and/or hypertension, history of cardiovascular disease (CVD), and high-density lipoprotein cholesterol level as adjustment factors. To explore risk reduction due to unspecified mechanisms other than LDLrC reduction, an estimated Kaplan-Meier curve from the Cox regression analysis was calculated and compared with the empirical (observed) Kaplan-Meier curve.

RESULTS

A total of 665 patients (527 women, 138 men; mean [SD] age, 72.8 [5.7] years) were enrolled in PATE and were followed up for a mean of 3.9 years (range, 3-5 years). Of those patients, 50 men and 173 women were ⩾75 years of age. Data from 619 patients were included in the present analysis. In the calculation of model-based Kaplan-Meier curves, data from an additional 32 patients were excluded from the LDL-C analysis because there were no data on pretreatment LDL levels; hence, the data from 587 patients were analyzed. A reduction in LDL-C level of 20 mg/dL was associated with an estimated CVE risk reduction of 24.7% (hazard ratio [HR] = 0.753; 95% CI, 0.625-0.907; P = 0.003). Risk was reduced by 22.2% in patients aged <75 years (HR = 0.778; 95% CI, 0.598-1.013; P = NS) and 29.9% in patients aged ⩾75 years (HR = 0.701; 95% CI, 0.526-0.934; P = 0.015). The risk reductions were 19.8% in women (HR = 0.802; 95% CI, 0.645-0.996; P = 0.046) and 35.8% in men (HR = 0.642; 95% CI, 0.453-0.911; P = 0.013). The risk reduction was 32.4% in patients without a history of CVD at enrollment (HR = 0.676; 95% CI, 0.525-0.870; P = 0.002) and 15.1% in those with a history of CVD (HR = 0.849; 95% CI, 0.630-1.143; P= NS). The estimated Kaplan-Meier curve strongly suggested that the effects of pravastatin were only partially associated with changes in LDLrC level.

CONCLUSIONS

The results from this post hoc analysis suggest that pravastatin 5 to 20 mg/d might elicit CVE risk reduction by mechanisms other than cholesterol-lowering effects alone. They also suggest that pravastatin treatment might be effective in reducing the risk for CVEs in both female and male patients aged ⩾75 years.

Treatment of Hyperlipidemia from Japanese Evidence

The treatment of hyperlipidemia is aimed at preventing cardiovascular disease (CVD) and coronary heart disease (CHD). As the incidence of CHD in Japan is about one-third lower and that of stroke is two-fold higher compared to Western countries, and the doses of lipid-lowering drugs used in foreign randomized controlled clinical trials (RCTs) are much higher than in general use in Japan, it remains unclear whether the results of RCTs conducted in Western countries could be extrapolated to Japanese patients. Recently, two major large-scale, prospective, RCTs in Japanese hypercholesterolmic patients, the Management of Elevated Cholesterol in the Primary Prevention of Adult Japanese (MEGA) study and the Japan EPA Lipid Intervention Study (JELIS), have been reported. Japanese epidemiological studies and Japanese clinical studies are reviewed. The evidence suggests that hypercholesterolemia, hypertriglyceridemia, and low HDL-cholesterol are strongly associated with increased CHD risk. Lipid-lowering medication shows beneficial effects even in low-risk populations; however, the data did not support that lower cholesterol is better. The safety and efficacy of hyperlipidemia treatment in Japanese patients are discussed.

Sex Differences of Risk Factors for Acute Myocardial Infarction in Japanese Patients

BACKGROUND

Acute myocardial infarction (AMI) is prevalent and has serious consequences including re-infarction and death. Although the risk factors for AMI have been extensively studied in Western countries, they are less well documented in Japan. To determine the risk factors for AMI, we performed a case-control study in unselected patients with AMI.

METHODS AND RESULTS

Risk factors were assessed in 1,925 consecutive patients with a first AMI (age, 28-103 years old; men, 1,353; women, 572), who were admitted to one of the major institutes in Japan, and in 2,279 age-and sex-matched population-based controls. Hypertension (odds ratio (OR), 4.80; 95% confidence interval (CI), 3.80 to 5.95; p < 0.01), diabetes (OR, 3.44; 95% CI, 2.50 to 4.75; p < 0.01), current smoking (OR, 3.39; 95% CI, 2.78 to 4.18; p < 0.01), family history (OR, 1.84; 95% CI, 1.30 to 2.62; p < 0.01), and hypercholesterolemia (OR, 1.28; 95% CI, 1.00 to 1.62; p < 0.05) were all independent risk factors for AMI. However, obesity (OR, 1.13; 95% CI, 0.92 to 1.50; NS) was not. Hypertension (OR, 4.80; 95% CI, 3.80 to 6.02; p < 0.01), current smoking (OR, 4.00; 95% CI, 3.02 to 5.00; p < 0.01), and diabetes (OR, 2.9; 95% CI, 2.00 to 4.04; p < 0.01) were all independent risk factors for AMI in men. In contrast, only current smoking (OR, 8.22; 95% CI, 3.98 to 18.88; p < 0.01), diabetes (OR, 6.12; 95% CI, 3.78 to 12.02; p < 0.01), and hypertension (OR, 5.04; 95% CI, 2.92 to 7.52; p < 0.01) were independent risk factors for AMI in women. Hypercholesterolemia was an independent risk factor for AMI in men (OR, 1.52; 95% CI, 1.00 to 1.98; p < 0.05), but not in women.

CONCLUSIONS

Hypertension, diabetes, current smoking, family history and hypercholesterolemia are associated with AMI in Japanese patients, and the importance of the risk factors for AMI differs between men and women. Hypertension, current smoking, diabetes and family history are the most important risk factors in men, whereas current smoking, diabetes, hypertension and family history are the most important risk factors in women. Hypercholesterolemia is an independent risk factor for AMI in men, but not in women. To the best of our knowledge, this is the first clinical study to define the relative importance of risk factors for AMI in Japanese patients.

Pleiotropic Effects of Statins: Benefit Beyond Cholesterol Reduction?

OBJECTIVES

This study sought to determine whether statins reduce coronary heart disease (CHD) risk more than other interventions that also primarily lower low-density lipoprotein cholesterol (LDL-C).

BACKGROUND

Statins have anti-inflammatory, immunomodulatory, antithrombotic, vascular, and other non-LDL-C-lowering effects. It is unclear whether these pleiotropic effects contribute to cardiovascular risk reduction beyond that expected from LDL-C reduction alone.

METHODS

Trials published in English language journals were retrieved by searching Medline (1966 to October 2004), bibliographies, and the author's reference files. Randomized, placebo-controlled trials of interventions to primarily lower LDL-C of three or more years' duration in which clinical disease or death were primary outcomes were used. Information on sample size, treatment type and duration, participant characteristics at baseline, reduction in lipids, and outcome was independently abstracted by two authors (J.R. and N.M.) using a standardized protocol. Data from 5 diet, 3 bile acid sequestrant, 1 surgery, and 10 statin trials, with 81,859 participants, were included in the CHD meta-regression analysis.

RESULTS

The regression lines for non-statin and statin trials were similar and consistent with a one-to-one relationship between LDL-C lowering and CHD and stroke reduction over five years of treatment.

CONCLUSIONS

The pleiotropic effects of statins do not seem to contribute an additional cardiovascular risk reduction benefit beyond that expected from the degree of LDL-C lowering observed in other trials that primarily lowered LDL-C.

Quelle signification pour le taux de cholestérol après 75 ans?

Increasing comorbidity with aging reduces the predictive power of cardiovascular risk factors. From the age of 70 onward, total cholesterol levels decrease, perhaps associated with changes in the composition of some lipoprotein fractions. In subjects older than 75 years, being in the lowest quartile of cholesterol, insulinemia or serum albumin concentrations is associated with increased mortality. Cholesterol levels below 189 mg/dL in subjects older than 75 years should be considered an early sign of unidentified comorbidity or of rapid functional decline. HDL cholesterol levels, rather than total or LDL cholesterol, were inversely associated with increased mortality from ischemic coronary disease and stroke appears to rise as HDL cholesterol levels fall, rather than total or LDL cholesterol. On the other hand, LDL concentrations below 106 mg/dL and HDL concentrations below 36 mg/dL were associated with an increased risk of death from infectious disease. Stroke incidence, in particular, ischemic stroke, is highest in subjects older than 75 years. HDL cholesterol levels above 35 mg/dL appear to have a protective effect against ischemic stroke in subjects younger than 70 years. Two interventional drug studies investigating the effects of two statins (simvastatin and pravastatin) found that in subgroups of subjects older than 75 these drugs were associated with a reduction in all-cause mortality and cardiovascular morbidity, regardless of total cholesterol levels, but had no short-term effect on cognitive function.

Statins and fibrates for preventing melanoma

BACKGROUND

Effective treatment for advanced melanoma is lacking. While no drug therapy currently exists for prevention of melanoma, in vitro, case-control, and animal model evidence suggest that lipid-lowering medications, commonly taken for high cholesterol, might prevent melanoma.

OBJECTIVES

To assess the effects of statin or fibrate lipid-lowering medications on melanoma outcomes.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (February 2003), CENTRAL (The Cochrane Library Issue 1, 2005), MEDLINE (to March 2003), EMBASE (to September 2003), CANCERLIT (to October 2002), Web of Science (to May 2003), and reference lists of articles. We approached study investigators and pharmaceutical companies for additional information (published or unpublished studies).

SELECTION CRITERIA

Trials involving random allocation of study participants, where experimental groups used statins or fibrates and participants were enrolled for at least four years of therapy.

DATA COLLECTION AND ANALYSIS

Three authors screened 109 abstracts of articles with titles of possible relevance. We then thoroughly examined the full text of 72 potentially relevant articles. We requested unpublished melanoma outcomes data from the corresponding author of each qualifying trial.

MAIN RESULTS

We identified 16 qualifying randomised controlled trials (RCTs) (seven statin, nine fibrate). Thirteen of these trials (involving 62,197 participants) provided data on incident melanomas (six statin, seven fibrate). A total of 66 melanomas were reported in groups receiving the experimental drug and 86 in groups receiving placebo or other control therapies. For statin trials this translated to an odds ratio of 0.90 (95% confidence interval 0.56 to 1.44) and for fibrate trials an odds ratio of 0.58 (95% confidence interval 0.19 to 1.82). Subgroup analyses failed to show statistically significant differences in melanoma outcomes by gender, melanoma occurrence after two years of participation in trial, stage or histology, or trial funding. Subgroup analysis by type of fibrate or statin also failed to show statistically significant differences, except for the statin subgroup analysis which showed reduced melanoma incidence for lovastatin, based on one trial only (odds ratio 0.52, 95% confidence interval 0.27 to 0.99).

AUTHORS' CONCLUSIONS

The melanoma outcomes data collected in this review of RCTs of statins and fibrates does not exclude the possibility that these drugs prevent melanoma. There was a 10% and 42% reduction for participants on statins and fibrates, respectively, however these results were not statistically significant. Until further evidence is established, limiting exposure to ultraviolet radiation remains the most effective way to reduce the risk of melanoma.

Electrocardiographic events and cholesterol reduction with pravastatin in patients with hypercholesterolemia: the Hokuriku Lipid Coronary Heart Disease Study-Pravastatin Atherosclerosis Trial

BACKGROUND

Cholesterol lowering therapy may offset the development of coronary atherosclerosis, and the resulting reduction in coronary ischemia may be observed in the electrocardiogram (ECG).

METHODS

A total of 2039 Japanese adults with hypercholesterolemia were divided into two groups (receiving 10-20 mg pravastatin daily or a normal diet) and were followed up for 5 years. ECG studies were performed at entry and every year during the follow-up period. The occurrence of myocardial infarction and the appearance or worsening of ischemic ST changes were assessed in terms of effects on the ECG.

RESULTS

Of the 2039 patients registered, 827 were excluded from the study for various reasons. Consequently, a total of 1212 patients were analyzed. There was a lower degree of worsening in the pravastatin group (n=757) than in the normal diet group (n=455) in the primary prevention cohort [11 (1.8%) vs. 16 (4.3%), respectively, P=0.031]. On the other hand, there was no difference in the frequency of worsening between the two groups in the secondary prevention cohort [7 (4.4%) in the pravastatin group vs. 4 (4.9%) in the diet group, P=0.25]. Event-free survival was better in the pravastatin group than in the normal diet group in the primary prevention cohort (P=0.011), but there was no difference between the two groups in the secondary prevention cohort.

CONCLUSIONS

These results suggest that pravastatin may reduce the incidence of coronary heart disease and that this effect may be predominantly observed in patients with early atheromatous lesions.

Status of lipid-lowering therapy prescribedbased on recommendations in the 2002 report of the Japan Atherosclerosis Society Guideline for Diagnosis and Treatment of Hyperlipidemia in Japanese Adults: A study of the Japan Lipid Assessment Program (J-LAP)

BACKGROUND

In its 1997 Guideline for Diagnosis and Treatment of Hyperlipidemia in Japanese Adults and subsequent revisions, the Japan10 Atherosclerosis Society (JAS) recommends serum lipid management goals (SLMGs) based on a coronary heart disease (CHD) risk classification. A literature search revealed that the status of lipid-lowering therapy based on the current JAS recommendations in Japan has not been assessed.

OBJECTIVE

The aim of this study was to evaluate the efficacy of current lipid-lowering 10 regimens, and to provide the best possible therapeutic strategies for patients with hyperlipidemia by identifying risk factors for the development of CHD, based on the current JAS recommendations.

METHODS

This multicenter, retrospective study was conducted using data 10 from patients under the care of physicians at 12,500 randomly selected institutions across Japan. Physicians received a survey concerning lipid-lowering therapy, on which each physician provided data from 10 consecutive adult patients with hyperlipidemia who had been prescribed lipid-lowering therapy for at least 3 months before the survey was administered, and who were undergoing routine follow-up on an outpatient basis. Physicians provided patients' demographic and clinical data, including JAS-defined CHD risk classification coronary risk factors and pre- and posttreatment (after ≥3 months) serum lipid levels, and the types and dosages of drugs in patients' current and prior treatment regimens. These data were used to assess the efficacy of lipid-lowering regimens and rates of patients achieving the SLMGs recommended by the JAS.

RESULTS

A total of 2540 physicians participated in the survey, and data from 10 24,893 Japanese patients (mean [SD] age, 65.8 [10.5] years) with hyperlipidemia were included in the study. Patients with familial hyperlipidemia (845/24,893 [3.4%]) were excluded from most of the analyses, leaving 24,048 patients with primary hyperlipidemia. The most prevalent coronary risk factors included age (21,902 [91.1%]), hypertension (14,275 [59.4%]), diabetes mellitus type 2 and/or impaired glucose tolerance (6346 [26.4%]), and smoking (3841 [16.0%]). A total of 20,948 patients (87.1%) had a CHD risk classification of B (ie, ≥1 coronary risk factor but no history of CHD). At the time of the survey, the lipid-lowering regimens of 22,080 patients (91.8%) included a statin. The rates of achievement of SLMGs were as follows: total cholesterol (TC), 12,659/23,840 patients (53.1%); low-density lipoprotein cholesterol (LDL-C), 14,025/22,121 (63.4%); high-density lipoprotein cholesterol, 19,702/21,279 (92.6%); and triglycerides (TG), 14,892/ 23,569 (63.2%). TC and LDL-C goals were achieved by most patients (≥61.1%) in risk categories A, B1, and B2 (ie, 0-2 coronary risk factors; low to moderate risk) but by a low percentage of patients (≤45.4%) in risk categories B3, B4, and C (ie, ≥3 coronary risk factors or history of CHD; high risk). In the high-risk group (n = 10,515), the TC goal was achieved by 4059 patients (38.6%). The TC and LDL-C goals were achieved by significantly higher percentages of patients prescribed atorvastatin (5133/7928 [64.7%] and 5487/7426 [73.9%], respectively) compared with the rates of patients prescribed any other statin at the recommended starting doses (all, P < 0.05).

CONCLUSIONS

The results of this study of Japanese patients undergoing lipid-lowering 10 therapy for the prevention of CHD, prescribed based on the recommendations in the JAS guideline, suggest insufficient reduction of TC, LDL-C, and TG in patients at high risk for CHD and the need for more aggressive lipid-lowering therapy in such patients.

Cholesterol-independent effects of statins and new therapeutic targets: ischemic stroke and dementia

The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or "statins", are used as cholesterol-lowering agents worldwide. Statins inhibit cholesterol biosynthesis, leading to enhanced uptake of low-density lipoprotein (LDL) from the circulation via LDL receptors. This strong cholesterol-lowering action contributes to the beneficial effects of statins. For example, large clinical trials have demonstrated that statins significantly reduce cardiovascular risk. Recent research has shown that statins have other multiple actions involved in endothelial function, cell proliferation, inflammatory response, immunological reactions, platelet function, and lipid oxidation. These "pleiotropic actions" of statins probably provide a significant contribution to the reduction of cardiovascular events. This review summarizes the pleiotropic actions of statins in both basic and clinical studies. It also considers the potential for statin therapy in the treatment of stroke and dementia.

Design and baseline characteristics of a study of primary prevention of coronary events with pravastatin among Japanese with mildly elevated cholesterol levels

BACKGROUND

Although cholesterol management reportedly reduces fatal and non-fatal coronary heart disease (CHD) events in subjects with or without evident atherosclerotic disease, it is still uncertain whether these benefits extend to Japanese.

METHODS AND RESULTS

The study group comprised 8,009 subjects with mildly elevated total cholesterol who were randomized to treatment with 10-20 mg pravastatin plus diet (2,691 women, 1,267 men) or diet alone (2,758 women, 1,293 men). The groups were extremely well balanced with respect to baseline demographics and risk factors such as blood pressure and plasma lipids. Over a 5-year period of follow-up, the primary end-points will be a composite of fatal and non-fatal coronary events. Secondary end-points will include stroke and transient ischemic attack, all cardiovascular events and total mortality.

CONCLUSIONS

The 2 groups will be followed up until the end of March 2004 and end-points will be analyzed by full analysis set.

Increased risk for cardiovascular outcomes and effect of cholesterol-lowering pravastatin therapy in patients with diabetes mellitus in the pravastatin anti-atherosclerosis trial in the elderly (PATE)

BACKGROUND

The Pravastatin Anti-atherosclerosis Trial in the Elderly (PATE) was the first large-scale, prospective clinical trial to show that cholesterol-lowering therapy with pravastatin is effective in reducing the risk for cardiovascular events (CVEs) in elderly (aged ≥60 years) patients with hypercholesterolemia. PATE also included a subgroup of patients with diabetes mellitus (DM).

OBJECTIVE

The aim of this post hoc analysis was to assess the effects of lon-gtermpravastatin therapy on cardiovascular outcomes in the subgroup of patients with DM compared with a subgroup without it.

METHODS

PATE was conducted at 50 hospitals, universities, and clinics acrossJapan. Patients were randomly allocated to 1 of 2 treatment groups: low-dose pravastatin (5 mg PO QD; L group) or standard-lose pravastatin (in Japan, 10 mg PO QD; S group). Treatment was given for 3 to 5 years. Serum cholesterol levels were measured and the prevalence of CVEs was determined. The primary end point of the study was the S:L risk ratio for fatal or nonfatal CVEs. The secondary end point was the effect of diabetic patients' glycemic control on CVEs.

RESULTS

A total of 665 patients (527 women, 138 men; mean [SD] age, 72.8[5.7] years) were followed up for a mean of 3.9 years (range, 3-5 years). Among these, 199 patients had DM; 104 patients with DM were allocated to the L group and 95 to the S group. Four hundred sixty-six patients did not have DM (L group, 230 patients; S group, 236 patients). Overall, between 3 months and 3 years after the initiation of treatment, patients in the L group (mean dose, 4.5 mg/d) experienced reductions from baseline total cholesterol level of 11% to 13%. Those in the S group (mean dose, 8.3 mg/d) experienced reductions from baseline of 15% to 17%. Decreases in low-density lipoprotein cholesterol (LDL-C) levels were 17% to 20% and 23% to 26% in the L and S groups, respectively. Statistically similar reductions were noted between patients with DM and those without it in response to either dose. The DM subgroup experienced 32 CVEs (L group, 17; S group, 15) compared with 39 CVEs (L group, 25; S group, 14) in the subgroup without DM. The S:L CVE risk ratio (primary end point) was 0.94 (95% Cl, 0.46-1.92) in patients with DM and 0.54 (95% Cl, 0.28-1.05) in those without DM; the differences between the treatment groups were not statistically significant. The risk for CVEs in patients with DM whose glycosylated hemoglobin concentrations were <8.0% and ≥8.0% were, respectively, 1.87-fold (95% Cl, 1.09-3.20; P = 0.02) and 3.79-fold (95% Cl, 1.92-7.48; P < 0.01) higher than that in patients without DM.

CONCLUSIONS

In this post hoc analysis of the effects of long-term cholesterol-loweringtherapy (low- and standard-dose pravastatin) on cardiovascular outcomes in elderly patients with DM, dose had no effect on the risk for CVEs in these patients as it did in those without DM. Poorer glycemic control in patients with DM was related to a higher risk for CVEs. The lack of pravastatin efficacy found in the subgroup with DM may have been attributable to the small differences in LDL-C levels found between the 2 treatment groups and/or the small sample size of the study.

More Western hypercholesterolemic patients achieve Japan Atherosclerosis Society LDL-C goals with rosuvastatin therapy than with atorvastatin, pravastatin, or simvastatin therapy

BACKGROUND

Data from Western comparative trials suggest that rosuvastatin is more effective than atorvastatin, simvastatin, and pravastatin in helping hypercholesterolemic patients achieve US and European lipid-lowering guidelines. The purpose of this analysis was to assess the comparative efficacy of rosuvastatin in reducing low-density lipoprotein cholesterol (LDL-C) to levels recommended by the Japan Atherosclerosis Society (JAS).

METHODS AND RESULTS

A post hoc analysis of data from 6 randomized, double-blind, active-controlled trials was conducted to evaluate the relative efficacy of rosuvastatin and comparator statins in helping patients achieve the LDL-C goals established by the JAS. The first 5 trials, prospectively designed for pooling, were originally conducted to compare the effects of rosuvastatin with either atorvastatin, simvastatin, or pravastatin in reducing lipid levels and helping patients achieve the LDL-C goals established by the National Cholesterol Education Program. The 6th trial was conducted with similar objectives, but in patients with heterozygous familial hypercholesterolemia (HeFH). Data from 2,139 hypercholesterolemic patients in the first 5 trials were pooled for analysis: rosuvastatin 5 mg (n=390) or 10 mg (n=389) vs atorvastatin 10 mg (n=393); rosuvastatin 5 mg (n=240) or 10 mg (n=226) vs simvastatin 20 mg (n=249) or pravastatin 20 mg (n=252). In the studies with atorvastatin as the comparator, JAS-defined LDL-C goals were reached by 67.2% of the rosuvastatin 5-mg group, 82.3% of the rosuvastatin 10-mg group, and 58.0% of the atorvastatin 10-mg group (p<0.001 for both rosuvastatin groups vs atorvastatin) at 12 weeks. Similarly, in the trials with pravastatin and simvastatin as comparators, the JAS LDL-C goals were reached by 77.5% of the rosuvastatin 5-mg group, 86.7% of the rosuvastatin 10-mg group, 45.2% of the pravastatin 20-mg group and 65.5% of the simvastatin 20-mg group (p<0.001 for both rosuvastatin groups vs pravastatin and simvastatin). In the trial of HeFH patients (n=433 for rosuvastatin, n=187 for atorvastatin), 31.9% of patients treated with rosuvastatin 20 mg achieved JAS LDL-C goals, compared with 17.6% of patients treated with atorvastatin 20 mg (p<0.001).

CONCLUSIONS

Rosuvastatin has demonstrated clinical superiority over atorvastatin, pravastatin, and simvastatin in reducing LDL-C levels and in enabling patients to reach goals established by the JAS.