Back in March 2004, intensive lowering of LDL down to 79mg/dL using high dose atorvastatin reduced progression of coronary atherosclerosis as demonstrated by intravascular ultrasound (IVUS) compared to moderate lowering of LDL down to 110mg/dL using standard dose pravastatin. A month later, intensive lowering of LDL down to 62mg/dL using high dose atorvastatin lead to better cardiovascular outcomes than moderate lowering of LDL down to 95mg/dL using standard dose pravastatin.
In fact, the intensive regimen was associated with no change in plaque progression while the moderate regimen was associated with continued plaque progression. But as I've noted previously, plaque volume is a laboratory measure as opposed to cardiovascular events & outcomes, which are what really matter to our patients. Therefore, it's nice to see correlation between these two studies.
I think this background information is germane to an announcement at yesterday's session of the AHA meeting w/simultaneous publication in NEJM that intensive lipid lowering, regardless of the agent used, leads to significant plaque regression. But similar to the limbo dance, just how low do you have to go? Regardless of whether the participant used rosuvastatin 40mg to achieve LDL-C of 62.6mg/dL & HDL-C of 50.4mg/dL or atorvastatin 80mg to achieve 70.2mg/dL & 48.6mg/dL, respectively, both regimens lead to similar amounts of plaque regression w/o any difference in safety and side-effect profiles.
As a physician who practices in the trenches, I can't wait for the publication of clinical outcomes from this trial. In the meantime, given that atorvastatin is going generic soon and brings about the same laboratory results as branded rosuvastatin, I think that you can safely follow your pocketbook as long as you can tolerate the high dose necessary to achieve these results.
By the way, I don't directly own any stock in nor receive remuneration from either (or any) pharmaceutical company. And less you think I'm just another pill pusher, I would much rather my patients achieve these intensively low LDL goals via lifestyle but unfortunately, the reality is that most will need pharmaceutical assistance.
One more point: my philosophy, as yet unproven and certainly not backed by evidence-based medicine, is that all patients should attempt to achieve the same LDL goals as per this study rather than be satisfied w/risk stratification. After all, why settle for getting tutored to a C or D grade? If you're going to pay for tutoring, why not study enough to get an A or B? Likewise, if you're going to take a statin, why not take enough to achieve the best possible outcome?
Tweet
No comments:
Post a Comment