Intensive lipid lowering adds additional benefit

General

Clinical Question:
Does high-dose statin therapy provide additional benefit over moderate doses in patients with pre-existing heart disease?

Bottom Line:
Intensive statin therapy will decrease overall mortality rates compared with lower doses in patients with a recent history of acute coronary syndrome (ACS) but not in patients with stable coronary heart disease. However, 80 patients must be treated to prevent 1 additional death over 2 years. Intensive treatment decreases overall hospital admissions for heart failure in both groups and decreases major cardiac events in patients with stable coronary heart disease, but, again, the results are not striking. (LOE = 1a)

Reference:
Afilalo J, Majdan AA, Eisenberg MJ. Intensive statin therapy in acute coronary syndromes and stable coronary heart disease: a comparative meta-analysis of randomised controlled trials. Heart 2007;93(8):914-921.  [PMID:17277349]

Study Design:
Meta-analysis (randomized controlled trials)

Setting:
Outpatient (specialty)

Synopsis:
The researchers conducting this meta-analysis combined available research evaluating the effectiveness of intense cholesterol lowering in patients with recent ACS and in patients with stable coronary heart disease. To identify the studies, the authors searched several databases, including the Cochrane Central Register of Controlled Trials. They also searched reference lists of retrieved articles and proceedings from major cardiology conferences. They selected randomized controlled trials of at least 6 months' duration comparing high-dose lipid-lowering treatment (eg, simvastatin 80 mg/day) with lower doses of statin treatment (eg, simvastatin 20 mg per day or less). They included research in any language and performed a validity assessment. Two researchers independently abstracted the data for combination. They combined the results of 6 trials enrolling a total of 110,271 patient-years. In patients with recent ACS (n = 8655), deaths over the following 2 years occurred in 3.5% of patients treated with high doses as compared with 4.6% patients treated with lower doses (number needed to treat [NNT]= 80; 95% CI, 59 - 133). Intensive statin therapy had no effect on mortality in patients with coronary heart disease (n = 18,501) over 4.7 years. There was too much heterogeneity between the 2 studies evaluating major adverse cardiovascular events in patients with recent ACS, though intensive treatment significantly decreased major events in patients with coronary heart disease (odds ratio = .82; 95% CI, 0.75 - 0.91). Hospital admissions for heart failure were also decreased by intensive therapy for both types of patients. Patients receiving high-dose treatment are more likely to experience adverse hepatic events (number needed to treat to harm = 96).

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