The Pharmaceutical Journal
Vol 270 No 7243 p463
5 April 2003

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Atorvastatin reduces relative risk of heart attack by a third in hypertensives

Atorvastatin reduces the relative risk of myocardial infarction by more than a third in patients with hypertension at moderate risk of developing cardiovascular events, researchers report. However, this large reduction corresponds with an absolute reduction in cardiovascular events of less than four events per 1,000 patient years.

The finding comes from the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT). Initial results were announced last year (PJ, 19 October 2002, p558).

Of the 19,342 hypertensive patients who took part in ASCOT, only those with total cholesterol concentrations of 6.5mmol/L or less were eligible for the lipid-lowering part of the trial (10,305 patients). The researchers randomly assigned these patients, who on average were at moderate risk of developing cardiovasular events, to receive atorvastatin (Lipitor) 10mg or placebo daily.

Cholesterol lowering with atorvastatin conferred a 36 per cent reduction in fatal coronary heart disease (CHD) and non-fatal myocardial infarction compared with placebo (hazard ratio 0.64, 95 per cent confidence interval 0.50–0.83, P=0.0005). The benefit emerged early in the first year of follow-up and the trial was stopped early at the recommendation of the data safety monitoring board.

A 27 per cent reduction in stroke incidence was observed in those treated with atorvastatin compared with placebo, which the researchers say is "easily in keeping with the benefits of statins reported in previous studies". They point out that the magnitude of the benefits due to lipid-lowering are notably larger for CHD prevention than are the effects of blood pressure lowering in other randomised placebo-controlled trials, whereas the risk reduction in stroke seems somewhat smaller.

The researchers also found that after one-year of follow-up total cholesterol and low-density lipoprotein (LDL)-cholesterol among patients taking atorvastatin were 24 per cent and 35 per cent lower, respectively, than among those taking placebo. Total cardiovascular events and total coronary events were also lower in the atorvastatin group.

They say that the data reinforce the trend to adopt lower lipid-lowering treatment thresholds at least among patients with hypertension. The researchers conclude: "We hope our results will help to close the gap between what is recommended and the current suboptimal use of lipid-lowering treatment in clinical practice." (Lancet 2003;361:1149).

Data from the trial were presented this week at the American College of Cardiology congress held in Chicago (see p468).

A more cautionary message comes from Swedish researchers in an accompanying editorial. They say that although the lipid-lowering arm of the trial shows fairly large relative reductions in cardiovascular events, the additional benefit to effective blood pressure lowering is less impressive. They point out that the results of treatment were achieved in a select group of hypertensive patients at rather high risk of cardiovascular events. They estimate that lipid-lowering treatment in patients with good control of blood pressure would result in only a small increase in the probability of remaining free from a myocardial infarction over five years.

They add: "Any guideline changes should be left to the guidelines committees to decide when they balance the limited absolute benefits against the treatment cost of lipid lowering." (ibid, p1144.)