Intensive Statin Therapy 

• LDL-C reduction with statins predictably and safely lowers cardiovascular disease (CVD) risk regardless of baseline LDL-C. The benefit is directly proportional to the extent of LDL-C reduction and not the achieved LDL-C or baseline LDL-C.¹

• LDL-C reduction may be categorized as no reduction (<10 mg/dL; reference), small reduction (between 10 and 40 mg/dL), moderate reduction (between 40 and 70 mg/dL), or large reduction (> 70 mg/dL). Patients who achieve the largest reduction in LDL-C achieve the greatest clinical benefit regardless of age.² Moderate and large reductions in LDL-C require intensive statin therapy using higher doses of potent statins such as atorvastatin or rosuvastatin.

• Compared with less intensive or standard therapy, Intensive statin therapy, generally lowers LDL-C by an additional 20mg/dl. This results in a 15% further reduction in major vascular events(coronary death or heart attack -13% , coronary revascularization-19% , and ischemic stroke-16%).³

• Further reductions in LDL cholesterol safely produce definite further reductions in the incidence of heart attack, revascularization, and of ischemic stroke, with each 40 mg/dl reduction reducing the annual rate of these major vascular events by just over a 20%. There was no evidence of any threshold within the cholesterol range studied; suggesting that reduction of LDL cholesterol by 80-120 mg/dl would reduce risk by about 40-50%.

• Several studies have demonstrated that very low levels of LDL-C (LDL-C < 40 mg/dl) are not associated with increasing toxicity or side effects.^4-6 No significant effects were observed on deaths due to cancer or other non-vascular causes. ³

Intensive Statin Therapy for Indians

• In view of the heightened risk of heart attack at any given level of LDL, the Indo-US Health Summits have recommended lower threshold of Intervention and treatment target for LDL-C ─30 mg/dl lower than that recommended for each risk category. Such lower targets require intensive statin therapy using higher doses of atorvastatin or rosuvastatin depending on the baseline LDL-C and LDL-Goal as shown in Table 129 A.

• It is worth highlighting that in people with baseline LDL >160 mg/dl and LDL-C goal of <70 mg/dl only 71-74 % will achieve goal even with the highest approved doses of atorvastatin and rosuvastatin. Current evidence continues to support initiation of a potent statin with titration to achieve targets. Combinations may be useful in individuals unable to reach desired lipid levels on maximal tolerated doses of statins.^{7, 8} 

• In a comparative study of nearly 10,000 whites and 2000 South Asians in the UK, the prevalence of previous heart attack , or stroke was higher in South Asian men than in Caucasian men but the reverse was seen in women. More than 93% of South Asian men and nearly 68% Caucasian men older than 55 years have a CAD risk greater than 15% (equivalent to cardiovascular risk of 20%) and a cholesterol above135 mg/dl and would be eligible for treatment with lipid-lowering drugs. ¹¹ The equivalent proportions in women are 55% and 18% in South Asians and Caucasians, respectively.

• Treating this proportion of the population will have a societal impact, the majority of older people becoming patients, and although it may well be cost-effective for individuals, it will require substantial new resources.¹¹ This may be equally true for the Indian subcontinent.

Sources  

1. Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. Nov 13 2010;376(9753):1670-1681.

2. Rahilly-Tierney CR, Lawler EV, Scranton RE, Gaziano JM. Cardiovascular benefit of magnitude of low-density lipoprotein cholesterol reduction: a comparison of subgroups by age. Circulation. Oct 13 2009;120(15):1491-1497.

3. Cholesterol Treatment Trialists’ Ctt Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials. Lancet. Nov 13 2010;376(9753):1670-1681.

4.Enas EA, Chacko V, Pazhoor SG, Chennikkara H, Devarapalli HP. Dyslipidemia in South Asian patients. Curr Atheroscler Rep. Nov 2007;9(5):367-374.

5. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part I Benefits.Indian Heart J (In press) Indian Heart J (In press). 2011.

6. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part II Risks. Indian Heart J (In press). 2011.

7. Enas  EA, Singh V, Munjal YP, et al. Recommendations of the second Indo-U.S. health summit on prevention and control of cardiovascular disease among Asian Indians. Indian Heart J. May-Jun 2009;61(3):265-274.

8. Enas EA, Singh V, Munjal YP, Bhandari S, Yadave RD, Manchanda SC. Reducing the burden of coronary artery disease in India: challenges and opportunities. Indian Heart J. Mar-Apr 2008;60(2):161-175.

9. Nicholls SJ, Brandrup-Wognsen G, Palmer M, Barter PJ. Meta-analysis of comparative efficacy of increasing dose of Atorvastatin versus Rosuvastatin versus Simvastatin on lowering levels of atherogenic lipids (from VOYAGER). Am J Cardiol. Jan 1 2010;105(1):69-76.

10. Enas E.A., Hancy Chennikkara Pazhoor MD, Arun Kuruvila MBBS, Krishnaswami Vijayaraghavan MD F. Intensive Statin Therapy for Indians:Part I Benefits. Indian Heart J 2011; 63: 211-227.

11. Aarabi M, Jackson PR. Prevention of coronary heart disease with statins in UK South Asians and Caucasians. Eur J Cardiovasc Prev Rehabil. Apr 2007;14(2):333-339.