The Pharmaceutical Journal
Vol 275 No 7369 p397
1 October 2005

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Statins should be considered for all high-risk patients

Statins could reduce the incidence of major vascular events by a third and prolonged statin treatment with substantial cholesterol reductions should be considered in all patients at high risk of a major vascular event, a meta-analysis published online this week suggests (www.thelancet.com).

The analysis involved 90,056 people in 14 trials of atorvastatin (10mg), fluvastatin (40–80mg), lovastatin (20–80mg), pravastatin (20–40mg) and simvastatin (20–40mg), of whom 47 per cent had pre-existing coronary heart disease. It showed that a 1mmol/L reduction in LDL cholesterol led to a 12 per cent reduction in all-cause mortality and a 21 per cent reduction in any major vascular event, including a 17 per cent reduction in stroke, a 19 per cent reduction in coronary mortality and a 23 per cent reduction in myocardial infarction or coronary death, largely irrespective of patients’ initial lipid profiles.

Although current treatment guidelines recommend lowering LDL cholesterol to particular target levels, the authors argue that, since risk reductions are proportional to absolute LDL cholesterol reductions, statin treatment should aim to achieve substantial absolute reductions. “Full compliance with available statin regimens can reduce LDL cholesterol by at least 1.5mmol/L in many circumstances, and hence might be expected to reduce the incidence of major vascular events by about one third,” they say. “Ensuring that patients at high five-year risk of any type of occlusive major vascular event achieve and maintain a substantial reduction in LDL cholesterol would result in major clinical and public health benefits.”

In addition, although some observational studies have previously raised concerns that statins might increase the risk of gastrointestinal, respiratory and haematological cancers, the study found no evidence that statins increased the overall incidence of cancer, or the incidence at any particular site.

Helen Williams, pharmacy team leader for cardiac services at King’s College Hospital, said that the study’s findings support the shift in practice towards more aggressive lipid-lowering in patients at risk. “This may be used to justify the use of high-dose statin therapy for all, but other factors should also be considered, such as cost, risk of adverse effects and efficacy across dose range,” she said.

“Over-the-counter simvastatin at a dose of 10mg daily gives a reduction in LDL cholesterol of approximately 1.31mmol/L and, with this kind of efficacy, can therefore afford patients a significant reduction in cardiovascular events,” she said.

“Patients frequently ask pharmacists for additional information on the benefits of their statin therapy and for reassurance on safety. This study will help us as a profession give consistent advice on the outcomes associated with lipid lowering using statins and gives us confidence that these agents are safe with a trend towards reduced non-vascular mortality and no evidence of an increased incidence of cancer over five years.”