ATLANTA, March 10 - For all patients with stable coronary artery disease (CAD), the goal of therapy should be to get LDL cholesterol lower than 70 mg/dL, a Texas researcher said here.
New data from several trials suggest that such a target can be achieved safely, either with intensive statin monotherapy or with combinations of LDL-lowering medications, said Christie Ballantyne, M.D., director of the center for cardiovascular disease prevention at the Baylor College of Medicine in Houston.
Action Points
- Note that there appears to be a straight-line relationship between reducing LDL cholesterol and reducing the risk of cardiovascular events.
- For patients with stable coronary artery disease, consider intensive therapy - either statin monotherapy or combination therapy - to reduce LDL levels below 70 mg/dL.
"We can do this," he told a satellite symposium held just before the opening of the annual meeting of the American College of Cardiology here. "Less than 70 (mg/dL) makes sense (and) it can be achieved in the majority of patients," Dr. Ballantyne said.
Dr. Ballantyne noted that the ATP III LDL goals and cutpoints for therapy only suggest a goal of less than 70 mg/dL for patients considered to be at very high risk and even that is designated optional.
However, he said, two recent studies show that intensive statin monotherapy can reduce LDL levels safely to below 70 mg/dL, with a consequent reduction in cardiovascular events.
The Treating to New Targets study compared 10 mg/d of Lipitor (atorvastatin) to 80 mg/d of the same drug. Mean LDL levels in the low-dose arm were 101 mg/dL, compared with 77 in the high-dose arm.
The high-dose arm achieved a 22% relative risk reduction, compared to the low-dose arm, in the study's primary end-point, the occurrence of the first major cardiovascular event. (Hazard ratio 0.78; 95% confidence interval from 0.69 to 0.89; p<0.001).
The second study, the IDEAL trial, compared 80 mg/d of Lipitor with Zocor (simvastatin) beginning at 20 mg/d and rising to 40 mg/dL if total cholesterol remained high at 24 weeks.
The study did not achieve significance for its primary endpoint, a composite of coronary death, non-fatal MI, or resuscitation after cardiac arrest, but did show a significant benefit for high-dose Lipitor for some of the components, Dr. Ballantyne said. For instance, patients in the high-dose arm had a significant 17% relative risk reduction in non-fatal MI.
Importantly, both studies showed that the intensive statin monotherapy is safe; neither showed an increase in rhabdomyolysis, the major worry in statin therapy, Dr. Ballantyne said.
A major meta-analysis of statin studies, including more than 90,000 patients, shows a clear straight-line relationship between lowering LDL and reducing cardiac events, he said.
However, he said, reducing LDL cholesterol to below 70 mg/dL will in most cases require a reduction of at least 50%, while the reduction to be expected from standard doses of statins is between 30% and 40%.
The VYVA trial, reported last year in the American Heart Journal, showed that the combination of Zetia (ezetimibe) and Zocor led to greater reductions at all dose ranges than did Lipitor.
That combination, as well as high doses of Lipitor or high doses of Crestor (rosuvastatin), are options that can be used to achieve an LDL cholesterol reduction of greater than 50%, he said, although not all of the higher doses are recommended on FDA package inserts.
This satellite symposium was supported by an educational grant from Merck & Schering-Plough. Coverage of this symposium by 51˶ is supported by an educational grant from Reliant Pharmaceuticals, Inc.