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Intensive Statin Therapy for Indians

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 

Table 129 A. Percentage of Patients Achieving the LDL-C Goals. 9, 10

LDL-C Goal <70 mg/dL

LDL-C Goal <100 mg/dL

Baseline LDL-C in mg/dL

<130

130-160

>160

<130

130-160

>160

Rosuvastatin

5 mg/d

NA

0%

3%

NA

67%

38%

10 mg/d

47%

33%

11%

82%

76%

57%

20 mg/d

81%

57%

21%

95%

90%

65%

40 mg/d

84%

68%

32%

97%

95%

74%

Atorvastatin

10 mg/d

28%

9%

2%

71%

62%

29%

20 mg/d

65%

26%

4%

91%

84%

45%

40 mg/d

73%

45%

10%

97%

91%

57%

80 mg/d

76%

52%

18%

94%

86%

71%

  • 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.

 

 

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