[Statins in primary prevention of coronary heart disease]

Abstract

Lowering of LDL-cholesterol by 25 to 30% with statins resulted in a highly significant reduction of coronary event rates in 2 large primary prevention trials. In the West of Scotland Primary Prevention Study (WOSCOPS) hypercholesterolemic asymptomatic men were treated with either 40 mg of pravastatin or placebo, in the Airforce/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) 6605 men and women with average levels of LDL-cholesterol and low levels of HDL-cholesterol were treated with either 20 to 40 mg of lovastatin or placebo. Moreover, in the WOSCOP study a marked reduction of total mortality was observed which approached the level of statistical significance. Several groups of experts have recently developed guidelines for the use of statins in prevention of atherosclerotic vascular disease. There are major differences in the goals for lowering of LDL-cholesterol and in the levels at which initiation of lipid lowering by drugs is advocated. In most of these recommendations graded target levels for LDL-cholesterol are suggested which are guided by the level of global risk. According to the recommendations of the American National Cholesterol Education Program (NCEP) LDL-cholesterol should be lowered below 130 mg/dl in asymptomatic individuals at high absolute risk and below 160 in individuals with a moderate increase in risk. The Joint Task Force of European and other Societies on Coronary Prevention recently developed guidelines, which suggest that in primary prevention lipid lowering by drugs should be restricted to individuals whose 10 year CHD risk exceeds 20% or will exceed 20% if projected to age 60. In these individuals LDL-cholesterol levels should be lowered to less than 115 mg/dl. The International Task Force for Prevention of Coronary heart disease recently published recommendations which suggest, that LDL-cholesterol should be reduced below 100 mg/dl in asymptomatic individuals at very high coronary risk, while it should be lowered below 135 mg/dl in individuals at moderately increased risk and below 160 mg/dl in subjects with a small increase in risk. In conclusion, results of 2 landmark trials in primary prevention of coronary heart disease demonstrated that lowering of LDL-cholesterol by statins is one of the most effective strategies to reduce coronary risk. It should be applied most aggressively in subjects at the highest overall risk. Nevertheless, non-pharmacologic measures are still considered as the preferred strategy for the reduction of coronary risk in the setting of primary prevention.