The optimal low-density lipoprotein...

The optimal low-density lipoprotein cholesterol (LDL) entrance and approach to lipid lowering is not known. In the Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) trial, Nissen and colleagues compared the issues of a moderate statin regimen and an intensive lipid-lowering statin regimen upon atherosclerotic disease burden as measured through intravascular ultrasonography. Patients who were 30 to 75 years of age, who required coronary angiography for a clinical indication, and who demonstrated at least single obstruction with angiographic luminal diameter narrowing of 20 percent or more were enrolled

Baseline LDL cholesterol flats were between 125 and 210 mg by dL (3.24 and 5.43 mmol for L) after a four- to 10-week washout period. After a two-week run-in period, patients were randomized to receive 40 mg of pravastatin daily in the moderate regimen or 80 mg of atorvastatin daily in the intensive regimen. Patients underwent baseline angiography and ultrasound examination of the longest and least angulated target bottom which was required to have at least a 50 percent narrowing. Patients had clinical examinations each three months and repeat cardiac catheterization and intravascular ultrasonography after 18 months

A total of 2163 patients were protectioned Of these, a total of 502 patients had evaluable intravascular ultrasound deductions at baseline and 18-month follow-up (249 of those receiving pravastatin and 253 of those receiving atorvastatin). The mean LDL cholesterol flat was 79 mg per dL (204 mmol through L) in the atorvastatin arrange and 110 mg per dL (285 mmol for L) in the pravastatin arrange The reduction in C-reactive protein plain was 36.4 percent in the atorvastatin assign places to and 5.2 percent in the pravastatin group

The progression rate of atheroma book as measured by percent change was significantly lower in the atorvastatin cluster than in the pravastatin arrange with the former group showing no progression and the latter showing positive progression. The comes were unchanged in 22 subgroup varying according to age, previous statin use, baseline cholesterol evens or comorbidities, which could influence answer Patientoriented outcomes could not be evaluated because the number of clinical incidents during the trial was too small for analysis.

Overall, patients receiving atorvastatin showed significantly reduc coronary atherosclerotic progression compared with those receiving pravastatin. accrues favoring intensive lipid lowering were consistent for the primary fall of the curtain point, three specified secondary period points, and 22 prospectively defined subgroups

These findings indicate that a more intensive lipid-lowering regimen may achieve greater benefits and that these benefits are associated with LDL cholesterol horizontals well below current guidelines. Each 10 percent reduction in LDL cholesterol on a level corresponded with a 1 percent reduction in atheroma tome at the study's end. Of note, the lipid-lowering force may not be the solely mechanism mediating these cardiovascular benefits, because patients in the atorvastatin dispose also had significantly lower C-reactive protein flushs than those in the pravastatin assign places to Efficacy and safety appeared to be similar in as well-as; not only-but also; not only-but; not alone-but groups. Clinical outcome studies are necessary before implementing these findings in practice.

EDITOR'S NOTE: The contemplation by Nissen and colleagues appeared at the same time as a clinical consequences study of the same medications published in the strange England Journal of Medicine. (1) In that studious mood hospitalized patients with acute coronary syndrome were randomized to receive 40 mg of pravastatin or 80 mg of atorvastatin. issues were death from any cause and further vascular adventures After two years, the hazard ratio in the atorvastatin collection was reduced by 16 percent As in the ultrasound inquiry both drugs were similarly well tolerated, with equivalent dropout rates in as well-as; not only-but also; not only-but; not alone-but groups. Thus, the combined disease-oriented and patient-oriented evidence is compelling that patients with demonstrated cardiovascular disease do better with intensive lipid-lowering therapy. However, the absolute reductions are not large. Lifestyle measures are likely to have greater impact.--C.W.

REFERENCE

(1) Cannon CP Braunwald E McCabe CH Rader DJ Rouleau JL Belder R et al. Intensive versus moderate lipid lowering with statins after acute coronary syndrome N Engl J M 2004;350:1495-504

CAROLINE WELLBERY, MD

Nissen SE et al. import of intensive compared with moderate lipid-lowering therapy in succession progression of coronary atherosclerosis. A randomized controll trial. JAMA March 3 2004;291:1071-80

COPYRIGHT 2004 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group