Goals of statin therapy: three viewpoints

Atherosclerotic Cardiovascular Disease Risk and Evidence-based Management of Cholesterol

An elevated level of low-density lipoprotein cholesterol is directly associated with development of atherosclerotic cardiovascular disease, which may present as coronary heart disease, stroke, and peripheral arterial disease. The new cholesterol management guidelines from the American College of Cardiology and the American Heart Association aim to address a comprehensive approach to prevent and reduce the risk of atherosclerotic cardiovascular disease. The new guidelines recommend initiation of heart healthy lifestyle modifications and 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitor ("statin") therapy in individuals who are at a high risk for atherosclerotic cardiovascular disease. It is estimated that these guidelines could result in "statin" therapy for one in every three adults in the United States. This article presents a review of the current cholesterol management guidelines, recommendations from relevant randomized controlled trials and meta-analyses obtained from the searches in Medline/PubMed and Cochrane Database of Systematic Reviews, and publications from the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Service, and the United States Preventive Services Task Force.

Effect of dietary and antismoking advice on the incidence of myocardial infarction: a 16-year follow-up of the Oslo Diet and Antismoking Study after its close

BACKGROUND AND AIM

The Oslo Diet and Antismoking Study was a 5-year randomised controlled trial initiated in 1972-1973 and ended in 1977-1978, which showed that dietary change and smoking cessation reduced the incidence of coronary heart disease among high risk middle-aged men. In an extended follow-up we studied the incidence of myocardial infarction (MI) 16 years after the end of the trial in the intervention and control groups.

METHODS

The primary endpoint was the first occurrence of non-fatal and fatal MI including sudden death up to December 31 1993. Cases of fatal MI were identified by linkage to Statistics Norway using each subject's individual personal number. Cases of non-fatal MI were extracted from the hospital records. Cox proportional hazards regression models estimated relationships between changes in total cholesterol and triglyceride concentrations and smoking status and the primary endpoints up to 16 years following the end of the trial.

RESULTS

At 5 and 10 years following the end of the trial the incidence of MI among the 604 men in the intervention (I) and 628 in the control (C) group differed significantly (5-year event rate (I/C) =0.059/0.090; P=0.038 and 10-year event rate (I/C) =0.111/0.155; P=0.023), but the difference faded slowly and subsequently (P=0.069 at 16 years). The reduction in MI in the intervention group was primarily explained by the differences in total cholesterol and triglyceride concentrations between the groups.

CONCLUSION

This extended follow-up of the Oslo Diet and Antismoking Study found a prolonged benefit of the intervention lasting for at least a decade after the close of the trial. This finding is in accordance with statin and other studies showing that the effect of cholesterol lowering may be prolonged after the end of the intervention.