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Liu X, Zhu H, Zheng H, Sun L, Qiu M, Huang Y. Stains therapy and the risk of all bleeding and intracranial hemorrhage: A meta-analysis of randomized controlled studies. J Evid Based Med 2022; 15:373-384. [PMID: 36510635 DOI: 10.1111/jebm.12507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022]
Abstract
AIMS Statins had been used as a cornerstone in the primary and secondary prevention of cardiovascular disease. Widespread attention had been given to the risk of bleeding, especially intracranial hemorrhage (ICH) in patients receiving statins therapy. This study aimed to determine whether statins treatment was associated with the risk of bleeding and ICH in randomized controlled trials (RCTs). MATERIALS AND METHODS Electronic databases were searched for studies up to September 8, 2022. Articles from RCTs were included in the meta-analysis if they reported the bleeding events associated with the treatment of statins or placebo/nonstatin treatment. The risk ratios (RR) of total bleeding and ICH were pooled from the number of patients with each outcome in the statins and control groups from the included studies. RESULTS Twenty-nine studies comprising 145,929 individuals (2437 incident bleeding cases) were included in the meta-analysis. After a median follow-up duration of 3.65 years, statins treatment was not associated with the risk of all bleeding (RR = 1.03, 95% CI 0.93-1.15). Furthermore, in 26 studies comprising 144,177 participants, after a median follow-up duration of 3.95 years, statins treatment was not associated with the risk of ICH (RR = 1.05, 95% CI 0.84-1.31). Although in the subgroup analysis with patients with prior stroke, statins treatment showed an increased risk of ICH (RR = 1.47, 95% CI 1.07-2.01), sensitivity analysis showed that the result was unstable, which may be mainly driven by the SPARCL study. CONCLUSIONS Statins therapy is not associated with the risk of all bleeding and ICH. Although a mildly increased risk of ICH in patients with prior stroke is observed, which may be caused by chance finding and warrant further documentation.
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Affiliation(s)
- Xiong Liu
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
| | - Hailan Zhu
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
| | - Haoxiao Zheng
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
| | - Lichang Sun
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
| | - Min Qiu
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University (the First People's Hospital of Shunde), Foshan, China
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Guangzhou, China
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Nooromid M, Chen EB, Xiong L, Shapiro K, Jiang Q, Demsas F, Eskandari M, Priyadarshini M, Chang EB, Layden BT, Ho KJ. Microbe-Derived Butyrate and Its Receptor, Free Fatty Acid Receptor 3, But Not Free Fatty Acid Receptor 2, Mitigate Neointimal Hyperplasia Susceptibility After Arterial Injury. J Am Heart Assoc 2020; 9:e016235. [PMID: 32580613 PMCID: PMC7670501 DOI: 10.1161/jaha.120.016235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Arterial restenosis after vascular surgery is a common cause of midterm restenosis and treatment failure. Herein, we aim to investigate the role of microbe‐derived butyrate, FFAR2 (free fatty acid receptor 2), and FFAR3 (free fatty acid receptor 3) in mitigating neointimal hyperplasia development in remodeling murine arteries after injury. Methods and Results C57BL/6 mice treated with oral vancomycin before unilateral femoral wire injury to deplete gut microbiota had significantly diminished serum and stool butyrate and more neointimal hyperplasia development after arterial injury, which was reversed by concomitant butyrate supplementation. Deficiency of FFAR3 but not FFAR2, both receptors for butyrate, exacerbated neointimal hyperplasia development after injury. FFAR3 deficiency was also associated with delayed recovery of the endothelial layer in vivo. FFAR3 gene expression was observed in multiple peripheral arteries, and expression was increased after arterial injury. Treatment of endothelial but not vascular smooth muscle cells with the pharmacologic FFAR3 agonist 1‐methylcyclopropane carboxylate stimulated cellular migration and proliferation in scratch assays. Conclusions Our results support a protective role for butyrate and FFAR3 in the development of neointimal hyperplasia after arterial injury and delineate activation of the butyrate‐FFAR3 pathway as a valuable strategy for the prevention and treatment of neointimal hyperplasia.
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Affiliation(s)
- Michael Nooromid
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Edmund B Chen
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Liqun Xiong
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Katherine Shapiro
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Qun Jiang
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Falen Demsas
- Geisel School of Medicine at Dartmouth Hanover NH
| | - Maeve Eskandari
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
| | - Medha Priyadarshini
- Department of Medicine University of Illinois at Chicago and Jesse Brown VA Medical Center Chicago IL
| | - Eugene B Chang
- Section of Gastroenterology Department of Medicine University of Chicago, Chicago, IL
| | - Brian T Layden
- Department of Medicine University of Illinois at Chicago and Jesse Brown VA Medical Center Chicago IL
| | - Karen J Ho
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
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Judge C, Ruttledge S, Costello M, Murphy R, Loughlin E, Alvarez-Iglesias A, Ferguson J, Gorey S, Nolan A, Canavan M, O'Halloran M, O'Donnell MJ. Lipid Lowering Therapy, Low-Density Lipoprotein Level and Risk of Intracerebral Hemorrhage - A Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 28:1703-1709. [PMID: 30878368 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The association of lipid lowering therapy and intracerebral hemorrhage risk is controversial. METHODS We performed a cumulative meta-analysis of lipid lowering trials that reported intracerebral hemorrhage. Statin, fibrate, ezetimibe, PCSK9, and CETP trials were included. We explored whether the association of lipid lowering therapy and risk of intracerebral hemorrhage may vary by baseline low-density lipoprotein (LDL) level, mean change in LDL or baseline cardiovascular risk of population. RESULTS Among 39 trials (287,651 participants), lipid lowering therapy was not associated with a statistically significant increased risk of intracerebral hemorrhage (ICH) in primary and secondary prevention trials combined (odds ratio [OR], 1.12; 95% confidence interval [CI], .98-1.28). Lipid lowering was associated with an increased risk of ICH in secondary prevention trials (OR, 1.18; 95% CI, 1.00-1.38), but not in primary prevention trials (OR, 1.01; 95% CI, .78-1.30), but the test for interaction was not significant (P for interaction = .31). Meta-regression of baseline LDL or difference in LDL reduction between active and control did not explain significant heterogeneity between studies for ICH risk. Of 1000 individuals treated for 1 year for secondary prevention, we estimated 9.17 (95% CI, 5.78-12.66) fewer ischemic strokes and .48 (95% CI, .06-1.02) more ICH, and a net reduction of 8.69 in all stroke per 1000 person-years. CONCLUSIONS The benefits of lipid lowering therapy in prevention of ischemic stroke greatly exceed the risk of ICH. Concern about ICH should not discourage stroke clinicians from prescribing lipid lowering therapy for secondary prevention of ischemic stroke.
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Affiliation(s)
- Conor Judge
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland; Translational Medical Device Lab, NUI Galway, Galway, Ireland; Wellcome Trust - HRB Irish Clinical Academic Training, Ireland.
| | | | - Maria Costello
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Robert Murphy
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | | | | | - John Ferguson
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Sarah Gorey
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Aoife Nolan
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
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4
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Lu Y, Cheng Z, Zhao Y, Chang X, Chan C, Bai Y, Cheng N. Efficacy and safety of long-term treatment with statins for coronary heart disease: A Bayesian network meta-analysis. Atherosclerosis 2016; 254:215-227. [DOI: 10.1016/j.atherosclerosis.2016.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/06/2016] [Accepted: 10/13/2016] [Indexed: 01/11/2023]
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Zhou X, Mou Y, Shen X, Yang T, Liu J, Liu F, Dong J, Liao L. The role of atorvastatin on the restenosis process post-PTA in a diabetic rabbit model. BMC Cardiovasc Disord 2016; 16:153. [PMID: 27422557 PMCID: PMC4947282 DOI: 10.1186/s12872-016-0324-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 06/10/2016] [Indexed: 12/01/2022] Open
Abstract
Background Restenosis remains to be a major limitation of percutaneous transluminal angioplasty (PTA) for diabetic patients with peripheral vascular disease (PVD). Despite of stations routine implements to prevent such progress, its exact effect is unclear. Methods and results In our study, balloon was successfully implanted in the iliac artery of atherosclerotic rabbit. Patency of the narrowed artery was interrogated using ultrasound. Atorvastatin or vehicle was administered orally to rabbits from day 0 to day 28 after double-injury surgery. On day 7, day 14, and day 28, restenotic arteries were harvested and processed for histopathlogical analysis. Our data show that, after double-injury surgery, the intima was composed mostly by SMCs at all time course in rabbits undergoing surgery process. Significant increases in stenosis rates were noted from day 7 to day 14 (from 21 ± 5.85 % to 60.93 ± 12.46 %). On day 28 after double-injury surgery, severe restenosis was observed and daily administration of atorvastatin cannot prevent restenosis’ formation (88.69 ± 3.71 % vs. 90.02 ± 3.11 %, P > 0.05). The PCNA index and SMCs proliferation were correlated with the scores of the vascular pathology. Conclusions Our results indicate that double-injury model can mimic clinical restenosis, based on this model, atorvastatin showed no therapeutic effect on restenosis process in diabetic rabbits after PTA.
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Affiliation(s)
- Xiaojun Zhou
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Shandong University, No.16766, Jingshi Road, Lixia District, Jinan, 250000, Shandong Province, China
| | - Yaru Mou
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong University, Shandong University, Jinan, Shandong, China
| | - Xue Shen
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tianshu Yang
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ju Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong, China
| | - Fupeng Liu
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Shandong University, No.16766, Jingshi Road, Lixia District, Jinan, 250000, Shandong Province, China
| | - Jianjun Dong
- Department of Endocrinology, Qilu Hospital of Shandong University, No.44, wenhuan Road, Lixia District, Jinan, 250000, Shandong Province, China.
| | - Lin Liao
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Shandong University, No.16766, Jingshi Road, Lixia District, Jinan, 250000, Shandong Province, China.
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Takagi H, Umemoto T. Low-density lipoprotein-dependent and independent effects of statins on prevention of major coronary events: Meta-regression of randomized placebo-controlled trials. Int J Cardiol 2013; 168:4850-3. [DOI: 10.1016/j.ijcard.2013.07.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 07/03/2013] [Indexed: 11/24/2022]
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McKinney JS, Kostis WJ. Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke 2012; 43:2149-56. [PMID: 22588266 DOI: 10.1161/strokeaha.112.655894] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Statin therapy decreases the risk of ischemic stroke. An increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue, we performed a meta-analysis of randomized controlled trials using statins that reported ICH. METHODS We performed a literature search of Medline, Web of Science, and The Cochrane Library through January 25, 2012, and identified additional randomized controlled trials by reviewing reference lists of retrieved studies and prior meta-analyses. All randomized controlled trials of statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. Thirty-one randomized controlled trials were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses. RESULTS A total of 91,588 subjects were included in the active group and 91,215 in the control group. There was no significant difference in incidence of ICH observed in the active treatment group versus control (OR, 1.08; 95% CI, 0.88-1.32; P=0.47). ICH risk was not related to the degree of low-density lipoprotein reduction or achieved low-density lipoprotein cholesterol. Total stroke (OR, 0.84; 95% CI, 0.78-0.91; P<0.0001) and all-cause mortality (OR, 0.92; CI, 0.87-0.96; P=0.0007) were significantly reduced in the active therapy group. There was no evidence of publication bias. CONCLUSIONS Active statin therapy was not associated with significant increase in ICH in this meta-analysis of 31 randomized controlled trials of statin therapy. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.
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Affiliation(s)
- James S McKinney
- Cardiovascular Institute of New Jersey and the Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.
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8
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Alberton M, Wu P, Druyts E, Briel M, Mills EJ. Adverse events associated with individual statin treatments for cardiovascular disease: an indirect comparison meta-analysis. QJM 2012; 105:145-57. [PMID: 21920996 DOI: 10.1093/qjmed/hcr158] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Statins are the most widely prescribed drug available. Due to this reason, it is important to understand the risks involved with the drug class and individual statins. AIM We conducted a meta-analysis and employed indirect comparisons to identify differing risk effects across statins. DESIGN We included any randomized clinical trial (RCT) of atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin used for cardiovascular disease event prevention. The main outcome was adverse events [all-cause mortality, cancers, rhabdomylosis, diabetes, aspartate and alanine aminotransferase (AST/ALT), and creatinine kinase (CK) increases beyond the upper limit of normal]. In order to evaluate the relative effects of each drug on adverse events, we calculated adjusted indirect comparisons of the adverse-event outcomes. RESULTS Seventy-two trials involving 159,458 patients met our inclusion criteria. Overall, statin treatments significantly increased the rate of diabetes when compared to controls (OR: 1.09; 95% CI: 1.02-1.16) and elevated AST (OR: 1.31; 95% CI: 1.04-1.66) and ALT (OR: 1.28; 95% CI: 1.11-1.48) levels when compared to controls. Using indirect comparisons, we also found that atorvastatin significantly elevated AST levels compared to pravastatin (OR: 2.21; 95% CI: 1.13-4.29) and simvastatin significantly increased CK levels when compared to rosuvastatin (OR: 4.39; 95% CI: 1.01-19.07). Higher dose studies had increased risk of AST elevations. DISCUSSION Although statins are generally well tolerated, there are risks associated with almost all drugs. With few exceptions, statins appear to exert a similar risk across individual drugs.
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Affiliation(s)
- M Alberton
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
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Ribeiro RA, Ziegelmann PK, Duncan BB, Stella SF, da Costa Vieira JL, Restelatto LMF, Moriguchi EH, Polanczyk CA. Impact of statin dose on major cardiovascular events: a mixed treatment comparison meta-analysis involving more than 175,000 patients. Int J Cardiol 2011; 166:431-9. [PMID: 22192281 DOI: 10.1016/j.ijcard.2011.10.128] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/22/2011] [Accepted: 10/29/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND The benefit of statins in the reduction of cardiovascular events was demonstrated in several placebo-controlled trials. More intensive therapy seems to be associated with greater benefit. Our objective was to compare different statin doses in the reduction of cardiovascular events and deaths, combining direct and indirect evidence, through mixed treatment comparisons (MTC). METHODS We conducted a systematic review in MEDLINE and Cochrane CENTRAL. A random-effects Bayesian MTC model was used to combine placebo-controlled and direct statin comparison trials. Intensity of statin doses was classified according to expected LDL-cholesterol reduction effect: ≤30% as low; 30-40%, intermediate, and ≥40%, high. Outcomes evaluated were non-fatal myocardial infarction (MI), stroke, coronary revascularization and coronary, cardiovascular and all-cause death. Inconsistency was assessed with split-node methodology. RESULTS 47 trials (11 with direct statin comparisons) were included. High doses reduced non-fatal MI by 28% (95% CI: 18%-36%) and by 14% (7%-21%) when compared to low and intermediate doses, respectively. High doses also diminished revascularization [RR versus low and intermediate doses of 0.81 (0.69-0.95) and 0.88 (0.77-0.99), respectively] and stroke [RR of 0.83 (0.68-0.99) against low doses]. Regimen intensity did not change death rates (e.g., for all-cause mortality, RRs of 0.93 (0.80-1.06) and 0.98 (0.87-1.08) for high vs. low and intermediate doses, respectively). No statistical inconsistencies were found in the analyses. CONCLUSIONS In this study, in which all available evidence from statin trials was simultaneously analyzed, the benefit of more intensive therapy was restricted to non-fatal events.
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Hackam DG, Woodward M, Newby LK, Bhatt DL, Shao M, Smith EE, Donner A, Mamdani M, Douketis JD, Arima H, Chalmers J, MacMahon S, Tirschwell DL, Psaty BM, Bushnell CD, Aguilar MI, Capampangan DJ, Werring DJ, De Rango P, Viswanathan A, Danchin N, Cheng CL, Yang YHK, Verdel BM, Lai MS, Kennedy J, Uchiyama S, Yamaguchi T, Ikeda Y, Mrkobrada M. Statins and intracerebral hemorrhage: collaborative systematic review and meta-analysis. Circulation 2011; 124:2233-42. [PMID: 22007076 DOI: 10.1161/circulationaha.111.055269] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data. METHODS AND RESULTS We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86-1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81-1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41-0.88). Substantial statistical heterogeneity was evident for the case-control studies (I(2)=66%, P=0.01), but not for the cohort studies (I(2)=0%, P=0.48) or randomized trials (I(2)=30%, P=0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results. CONCLUSIONS We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.
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Mills EJ, Wu P, Chong G, Ghement I, Singh S, Akl EA, Eyawo O, Guyatt G, Berwanger O, Briel M. Efficacy and safety of statin treatment for cardiovascular disease: a network meta-analysis of 170,255 patients from 76 randomized trials. QJM 2011; 104:109-24. [PMID: 20934984 DOI: 10.1093/qjmed/hcq165] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Statins represent the largest selling class of cardiovascular drug in the world. Previous randomized trials (RCTs) have demonstrated important clinical benefits with statin therapy. AIM We combined evidence from all RCTs comparing a statin with placebo or usual care among patients with and without prior coronary heart disease (CHD) to determine clinical outcomes. DESIGN We searched independently, in duplicate, 12 electronic databases (from inception to August 2010), including full text journal content databases, to identify all statin versus inert control RCTs. We included RCTs of any statin versus any non-drug control in any populations. We abstracted data in duplicate on reported major clinical events and adverse events. We performed a random-effects meta-analysis and meta-regression. We performed a mixed treatment comparison using Bayesian methods. RESULTS We included a total of 76 RCTs involving 170,255 participants. There were a total of 14,878 deaths. Statin therapy reduced all-cause mortality, Relative Risk (RR) 0.90 [95% confidence interval (CI) 0.86-0.94, P ≤ 0.0001, I(2)=17%]; cardiovascular disease (CVD) mortality (RR 0.80, 95% CI 0.74-0.87, P<0.0001, I(2)=27%); fatal myocardial infarction (MI) (RR 0.82, 95% CI 0.75-0.91, P<0.0001, I(2)=21%); non-fatal MI (RR 0.74, 95% CI 0.67-0.81, P ≤ 0.001, I(2)=45%); revascularization (RR 0.76, 95% CI 0.70-0.81, P ≤ 0.0001); and a composite of fatal and non-fatal strokes (0.86, 95% CI 0.78-0.95, P=0.004, I(2)=41%). Adverse events were generally mild, but 17 RCTs reported on increased risk of development of incident diabetes [Odds Ratio (OR) 1.09; 95% CI 1.02-1.17, P=0.001, I(2)=11%]. Studies did not yield important differences across populations. We did not find any differing treatment effects between statins. DISCUSSION Statin therapies offer clear benefits across broad populations. As generic formulations become more available efforts to expand access should be a priority.
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Affiliation(s)
- E J Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
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12
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Suzuki N, Kozuma K, Ueno Y, Nagaoka K, Kyono H, Ishikawa S, Watanabe H, Yokoyama N, Takeshita S, Isshiki T. Serial quantitative coronary analyses for the evaluation of one-year change in saphenous vein grafts. Ann Thorac Surg 2008; 85:525-9. [PMID: 18222257 DOI: 10.1016/j.athoracsur.2007.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 09/20/2007] [Accepted: 09/20/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND A paucity of data exists with respect to changes in whole saphenous vein grafts (SVGs) despite accelerated atherosclerosis within grafted saphenous vein conduits. In the present study, we evaluated the one-year change in SVGs by means of quantitative coronary analysis. METHODS This study enrolled consecutive 52 patients with 109 SVGs, who underwent coronary artery bypass graft surgery successfully. A follow-up study was performed in 33 patients with 65 SVGs after one year because 16 SVGs were obstructed (baseline, 8; follow-up period, 8), and 15 patients with 28 SVGs dropped out within one year. RESULTS Both minimal and mean lumen diameters decreased significantly (3.17 +/- 0.64 mm vs 2.41 +/- 0.57 mm, p < 0.001; 3.70 +/- 0.69 mm vs 2.92 +/- 0.70 mm, p < 0.001; respectively). Graft length also decreased significantly (107.1 +/- 25.8 vs 100.6 +/- 25.2 mm, p < 0.001). The graft shortening rate (graft shortening length/baseline graft length x 100) was greater than 5% in 33 vessels (51%) and greater than 10% in 23 vessels (35%). Coronary risk factors (smoking, diabetes mellitus, hypertension, dyslipidemia) did not reveal significant relationship with late loss of minimal and mean lumen diameters. CONCLUSIONS The present study showed a considerable and uniform lumen loss of SVGs after one year, irrespective of coronary risk factors. Graft length shortening was seen more than elongation.
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Affiliation(s)
- Nobuaki Suzuki
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan.
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Nishino M, Hoshida S, Kato H, Egami Y, Shutta R, Yamaguchi H, Tanaka K, Tanouchi J, Hori M, Yamada Y. Preprocedural Statin Administration can Reduce Thrombotic Reaction After Stent Implantation. Circ J 2008; 72:232-7. [DOI: 10.1253/circj.72.232] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | - Ryu Shutta
- Division of Cardiology, Osaka Rosai Hospital
| | | | | | | | - Masatsugu Hori
- Department of Cardiology, Osaka University Graduate School of Medicine
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Razzolini R, Tarantini G, Ossena G, Favaretto E, Bilato C, Manzato E, Dalla-Volta S, Iliceto S. Non-cardiovascular mortality, low-density lipoprotein cholesterol and statins: a meta-regression analysis. Cardiology 2007; 109:110-6. [PMID: 17700016 DOI: 10.1159/000105551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2006] [Accepted: 12/06/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND As of today, the effect of statins on non-cardiovascular mortality is still being debated. Single studies have not been able to provide definite answers. We performed a meta-regression analysis on randomized statin trials in order to provide evidence that non-cardiovascular mortality is related to statin treatment and low-density lipoprotein (LDL) cholesterol plasma level. METHODS We selected 29 randomized controlled trials of statins versus placebo, a total of 90,480 patients, with a follow-up of >12 months. Baseline and follow-up LDL levels and all-cause, cardiovascular and non-cardiovascular mortality were recorded. Weighted linear regression analysis was carried out separately for placebo and treatment groups. RESULTS LDL level was inversely related to overall mortality (p = 0.0105) and non-cardiovascular mortality (p = 0.0171) in the treatment group. By contrast, in the placebo group only non-cardiovascular mortality was inversely correlated to LDL (p = 0.0032). The regression lines have similar slopes and run almost parallel to each other, with the treatment line lying below the placebo line. To identify the threshold of risk for starting statin therapy, we analysed the relationship between baseline cardiovascular risk and overall mortality in the two groups. Both correlations are highly significant and regression lines intersect at a risk of 0.29% per year. This implies that the effects of statins are favourable when the baseline cardiovascular risk exceeds approximately 3% in 10 years. CONCLUSIONS A trend of increased non-cardiovascular mortality with decreased LDL exists both in placebo and treatment groups. However, at each given LDL cholesterol level, non-cardiovascular mortality is lower in treated patients. Therefore, statin therapy may improve the biological impact of LDL on non-cardiovascular mortality.
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Affiliation(s)
- Renato Razzolini
- Department of Cardiology, University of Padova Medical School, Padova, Italy.
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15
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Brener SJ, Ivanc TB, Poliszczuk R, Chen M, Tuzcu EM, Hu T, Frid DJ, Nissen SE. Antihypertensive therapy and regression of coronary artery disease: insights from the Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis (CAMELOT) and Norvasc for Regression of Manifest Atherosclerotic Lesions by Intravascular Sonographic Evaluation (NORMALISE) trials. Am Heart J 2006; 152:1059-63. [PMID: 17161053 DOI: 10.1016/j.ahj.2006.07.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 07/19/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with coronary artery disease (CAD), therapies designed to prevent clinical events are not always associated with significant reduction in coronary obstruction, as measured by quantitative coronary angiography. We set out to explore the relationship between quantitative coronary angiography parameters, baseline characteristics, and clinical events in a large trial of CAD regression with antihypertensive agents. METHODS AND RESULTS Patients randomized to amlodipine, enalapril, or placebo in the CAMELOT trial were followed for 24 months for major ischemic events. Among 431 patients participating in the angiographic and intravascular ultrasound substudy NORMALISE, 298 (99 amlodipine, 96 enalapril, and 103 placebo) had complete angiographic and intravascular ultrasound data. The patients did not differ significantly with respect to baseline characteristics (except for diabetes) or extent of CAD. After 24 months, the change in minimal lumen diameter (MLD) was -0.02 +/- 0.13 for amlodipine, -0.03 +/- 0.12 for enalapril, and -0.03 +/- 0.17 mm for placebo (P = .40). Major ischemic events occurred in 20.2%, 24%, and 25.2%, respectively (P = .68). There was no significant correlation between change in MLD and age, sex, statin therapy, or systolic blood pressure at baseline. The change in MLD did not differ in patients with and without cardiovascular events, regardless of treatment assignment (P = .54). Only the extent of CAD was independently predictive of ischemic events. CONCLUSION As compared to placebo, amlodipine treatment resulted in fewer ischemic events after 24 months of therapy, but the clinical benefit was not associated with a commensurate improvement in arterial lumen dimensions.
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Affiliation(s)
- Sorin J Brener
- Department of Cardiovascular Medicine and Biostatistics, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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16
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Abstract
More than 1 million percutaneous coronary interventions (PCIs) are performed yearly worldwide. Restenosis is the recurrent narrowing that can occur within 6 months following an initially successful PCI. Although drug-eluting stents have accomplished remarkable success, restenosis has not been eliminated and optimisation of both the polymers and drugs associated with them is desirable. This article reviews the presently available and potential preventive approaches against restenosis, including the sirolimus and paclitaxel drug-eluting stents.
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Affiliation(s)
- Pierre-Frédéric Keller
- Montreal Heart Institute, Department of Medicine, 5000 Belanger Street, Montreal, Canada
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17
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Balk EM, Karas RH, Jordan HS, Kupelnick B, Chew P, Lau J. Effects of statins on vascular structure and function: a systematic review. Am J Med 2004; 117:775-90. [PMID: 15541327 DOI: 10.1016/j.amjmed.2004.05.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2004] [Accepted: 05/20/2004] [Indexed: 11/20/2022]
Abstract
PURPOSE Statins reduce cardiovascular events by more than can be explained by their effects on lipids. We conducted a systematic review of how statins affect vascular structure and function, differences among statins, and correlations between the effects of statins on vascular outcomes and either lipid levels or cardiovascular outcomes. METHODS We primarily searched MEDLINE (1980 to March 2004) to identify all studies with at least 10 subjects that reported the effects of currently available statins on coronary artery stenosis, carotid intima-media thickness, and endothelial function (excluding studies of drug combinations and subjects with organ transplants). Meta-analyses were performed when feasible. RESULTS Statins decrease the progression and increase the regression of coronary artery lesions and luminal narrowing. Compared with placebo, statins decrease the likelihood of coronary artery restenosis (summary risk ratio = 0.85; 95% confidence interval: 0.77 to 0.95). Statins appear to slow the progression of carotid artery intima-media thickness. Although the effect of statins on coronary endothelial function is uncertain, statins appear to improve peripheral endothelial function. There is no conclusive evidence to suggest that individual statins differ in their effects on these outcomes. Studies generally found weak or no correlation between the effects of statins on vascular outcomes and lipid levels. No study showed a correlation between vascular effect and clinical outcome. CONCLUSION Statins slow the progression of, and may reverse, atherosclerosis. The magnitude of these effects, however, is small compared with the effects of statins on cardiovascular events. Statins also improve measures of vascular function, which may contribute to their clinical benefits. There is insufficient evidence to suggest that individual statins differ in their vascular effects.
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Affiliation(s)
- Ethan M Balk
- Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies
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18
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Abstract
Therapy with HMG-CoA reductase inhibitors (statins) has been shown to significantly reduce major coronary events and death in a wide range of individuals at risk for these events. In addition, recent observations suggest that some of the clinical benefits associated with statin therapy may be pleiotropic; that is, independent of their cholesterol-inhibiting action. It is clear that the clinical benefits associated with statin therapy far outweigh the risks; however, there may be important clinical differences among agents within the class, related to both benefits and drug safety. Evaluation of the benefit-to-risk profile for each available statin should include considering the results of randomised clinical outcome trials, the safety record of each agent, effect on lipoproteins and evidence of beneficial pleiotropic properties.Recently, data from several clinical outcome trials have shown that substantial benefits are associated with treatment with fluvastatin in diverse populations. In particular, data from two large, randomised clinical trials have demonstrated that fluvastatin is effective for secondary prevention of cardiac events in patients following coronary intervention procedures, and for primary prevention of cardiac events in renal transplant recipients. Pleiotropic benefits for fluvastatin have been shown in experimental and clinical studies as well. Fluvastatin was the first statin available as an extended-release product (fluvastatin XL 80mg); both formulations have demonstrated efficacy and safety in a wide range of patients. Taken together, these clinical outcomes and safety data suggest a strong benefit-to-risk profile for fluvastatin.
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Shelton J, Wang D, Gupta H, Wyss JM, Oparil S, White CR. The neointimal response to endovascular injury is increased in obese Zucker rats. Diabetes Obes Metab 2003; 5:415-23. [PMID: 14617227 DOI: 10.1046/j.1463-1326.2003.00296.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Restenosis after revascularization procedures is accelerated in persons with type 2 diabetes. AIM The current study tested the hypothesis that the neointimal response to endovascular injury is enhanced in female obese Zucker (OZ) rats, a model of type 2 diabetes. METHODS Animals were randomized to receive either a standard diet (SD) or a diabetogenic diet (DD) for 6 weeks. Four weeks later, balloon injury of the right common carotid artery was induced. All rats were euthanized 2 weeks after injury. Lean Zucker (LZ) rats served as controls. RESULTS At the time of death, plasma glucose was elevated in OZ rats fed a SD (208 +/- 13 mg/dl) and a DD (288 +/- 21 mg/dl) compared to corresponding LZ rats (SD: 153 +/- 8; DD: 132 +/- 7 mg/dl). The ratio of high-density lipoprotein cholesterol (HDLc) to total cholesterol (Totc), an index of atherogenicity, was reduced in OZ rats on both diets (SD: 0.77 +/- 0.06; DD: 0.80 +/- 0.09) compared to LZ controls (SD: 1.11 +/- 0.02; DD: 1.20 +/- 0.05). Histomorphometric analysis of injured arteries showed that the intima to media (I : M) ratio was significantly increased in OZ (1.37 +/- 0.07) compared to LZ (0.79 +/- 0.08) rats. Elevations in plasma glucose and triglycerides (Tg) correlated positively and decreases in HDLc negatively with an increased I : M ratio. Administration of the DD did not further enhance the I : M ratio in LZ (0.87 +/- 0.06) or OZ (1.29 +/- 0.09) rats. CONCLUSIONS These results suggest that neointima formation following endoluminal injury of the carotid artery is enhanced at an early stage in the development of diabetes mellitus.
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Affiliation(s)
- J Shelton
- Departments of Medicine, Vascular Biology & Hypertension Program of the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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20
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Selzman CH. Current approaches to therapy for vascular injury. Expert Opin Pharmacother 2001; 2:753-64. [PMID: 11336620 DOI: 10.1517/14656566.2.5.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vascular injury is a ubiquitous phenomenon which can be both occult (such as with hyperlipidemia) and overt (such as with angioplasty). While the exact pathophysiology differs between acute and chronic atherosclerosis, both lesions can be mechanistically explained by the vasculature's exaggerated response to injury. Pharmacological attempts to treat atherosclerotic cardiovascular disease can be categorised by their role in modifying this inflammatory response. This manuscript reviews current therapy for cardiovascular injury at two levels: the chronic smouldering atheromatous lesion and intimal hyperplasia associated with acute vascular intervention. In addition, future therapeutic strategies, based within this inflammatory paradigm, are discussed.
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Affiliation(s)
- C H Selzman
- Division of Cardiothoracic Surgery, Box C-310, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, Colorado 80262, USA.
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21
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Abstract
Atherosclerosis is often asymptomatic, unrecognized, and undertreated. Lumen irregularities are important angiographic findings that should be addressed aggressively through risk factor modification, medical therapy, and coronary revascularization. Both angiographic and clinical benefits have been demonstrated with lipid reduction therapy in randomized clinical trials. Coronary revascularization is indicated for symptom relief and improvement in quality of life in patients with acute coronary syndromes at "intermediate" and "high" risk of subsequent death or myocardial infarction. In patients following percutaneous coronary intervention (PCI), future cardiac events may be related to lumen renarrowing or to progression of atherosclerotic disease at sites remote from the site of coronary revascularization. The time course of restenosis is relatively self-limiting, generally occurring within 6-12 months after the procedure. Clinical events occurring > 1 year after PCI generally relate to new lesions or progression of existing atherosclerotic disease. Patients with diabetes mellitus may be at higher risk for late coronary events than nondiabetic patients. In post-coronary artery bypass surgery (CABG) patients, the majority of late events relate to degeneration of saphenous vein grafts. Lipid lowering therapy after coronary revascularization has been shown to prevent clinical events related to plaque instability and inhibit progression of saphenous vein graft disease. Thus, there are 2 goals in management of patients with symptomatic coronary artery disease: (1) to relieve the flow-limiting stenosis, and (2) to prevent future clinical events with aggressive lipid lowering and modification of other risk factors. Patients, specialists, and primary care physicians each need to take accountability for this risk-factor modification.
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Affiliation(s)
- J J Popma
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Evans PM. Therapy and clinical trials. Curr Opin Lipidol 2000; 11:339-41. [PMID: 10882353 DOI: 10.1097/00041433-200006000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ngoc-Anh L. Hyperlipidaemia and cardiovascular risk factors. Curr Opin Lipidol 2000; 11:331-3. [PMID: 10882351 DOI: 10.1097/00041433-200006000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Archbold RA, Timmis AD. Modification of coronary artery disease progression by cholesterol-lowering therapy: the angiographic studies. Curr Opin Lipidol 1999; 10:527-34. [PMID: 10680047 DOI: 10.1097/00041433-199912000-00008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Large randomized placebo-controlled trials have demonstrated that cholesterol lowering with statin therapy reduces the incidence of adverse cardiac events. Smaller angiographic studies have shown that coronary artery disease progression can be slowed and, in some cases, reversed by cholesterol-lowering interventions. These anatomical changes, however, are small and occur too slowly to account for the early clinical benefit. Current evidence suggests that plaque stabilization is the most important mechanism, by which cholesterol-lowering therapy reduces both the incidence of adverse cardiac events and coronary artery disease progression.
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Affiliation(s)
- R A Archbold
- Department of Cardiology, London Chest Hospital, UK
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