For primary prevention, a decision to initiate statin therapy is made on multiple factors (i.e., presence of diabetes or severe hypercholesterolemia, estimated 10-year risk or lifetime risk for ASCVD, presence of risk enhancing factors (e.g., metabolic syndrome and chronic kidney disease) and if in doubt, detection of subclinical atherosclerosis (e.g., coronary artery calcium ). The greatest risk reductions are attained by reducing LDL-C concentrations by at least 50% with a high intensity statin and if necessary, to achieve LDL-C < 55-70 mg/dL, combining a statin with ezetimibe or PCSK9 inhibitor. RCTs in such patients show that “lower is better” for cholesterol reduction. Highest priority for cholesterol-lowering therapy goes to patients with established ASCVD (secondary prevention). The latter three generally are reserved for patients with hypertriglyceridemia here they can be combined with statins that together lower non-HDL-C. Currently available cholesterol-lowering drugs are statins, ezetimibe, bempedoic acid, bile acid sequestrants, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, niacin, fibrates, and n-3 fatty acids (e.g., icosapent ethyl). The efficacy of lifestyle intervention is best demonstrated in epidemiological studies, whereas efficacy of drugs is revealed through RCTs. Atherogenic lipoproteins can be reduced by both lifestyle intervention and cholesterol-lowering drugs. Clinically these lipoproteins are identified by their cholesterol (C) content, i.e., LDL-C, VLDL-C, and non-HDL-C. Together they constitute non-high-density lipoproteins (non-HDL). The major atherogenic lipoproteins are low density lipoproteins (LDL), very low-density lipoproteins (VLDL), and remnants. Cholesterol in the circulation is embedded in lipoproteins. This hypothesis is based on epidemiological evidence that both within and between populations higher cholesterol levels raise the risk for ASCVD and conversely, randomized clinical trials (RCTs) show that lowering cholesterol levels will reduce risk. “Not only do we hope to continue studying this population, but we also hope to study patients without prior cardiovascular disease but who are at high risk for it,” said Rodriguez.The cholesterol hypothesis holds that high blood cholesterol is a major risk factor for atherosclerosis cardiovascular disease (ASCVD) and lowering cholesterol levels will reduce risk for ASCVD. The researchers also hope to follow up on longer-term data from these patient populations. The researchers said their next step is to find out why some patients who should be on high-intensity statins are not. Even in patients over 75 - a population that is largely ignored in studies - higher-intensity statins led to a 9 percent higher survival rate.Īs Fatima Rodriguez, MD, a cardiology fellow at Stanford and the study’s lead author, said in our release: "This suggests to practitioners that instead of starting a patient on a low dose, just to go ahead and put them on the maximum dose they can tolerate." Over a one-year duration, they found that patients on higher-intensity statins had a 9 percent higher survival rate as compared to those on moderate doses. Some prior studies have shown that powerful, high-intensity statins increased the rates of side effects such as diabetes or muscle damage, creating controversy around the types of statins doctors should prescribe to their patients, if at all.Īs Paul Heidenreich, MD, professor of cardiovascular medicine and the study’s senior author, told me: "Previously, there was a certain amount of fear on the patient’s part because most people don’t like taking medication."įor this study, Heidenreich and his colleagues studied the medical records of 509,766 patients in the Veterans Affairs Health Care System. A set of guidelines put forth by the American College of Cardiology and the American Heart Association categorizes them into low-intensity, moderate-intensity, and high-intensity statins based on their strength for reducing bad cholesterol. There are currently seven main types of statins prescribed in the United States. In a study publishing this week in JAMA Cardiology, Stanford researchers show that taking high-intensity statins could increase heart patients’ chances of survival over taking moderate-intensity statins.
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