This article originally posted 23 August, 2004 and appeared in Issue 222
Using Statins For Type 2's With Normal Cholesterol Concentrations
A statin reduced the death rate by 27% and strokes reduced by 48%.
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Results of a randomized trial in this week's issue of THE LANCET suggest that
people with type 2 diabetes could benefit from cholesterol-lowering therapy
with statins to reduce the risk of cardiovascular disease-even when they do
not have high cholesterol concentrations.
Many recent studies have shown the benefits of statin therapy to reduce the
risk of cardiovascular disease in various groups of patients. Whether most patients
with diabetes (who are known to be at increased cardiovascular risk) should
receive cholesterol-lowering therapy remains unclear, especially for those patients
who do not have High cholesterol.
Helen Colhoun (University College Dublin, Ireland, formerly at University College
London ) and colleagues assess the effectiveness of atorvastatin for the primary
prevention of major cardiovascular events in patients with type 2 diabetes without
high concentrations of LDL-('bad') cholesterol. Around 2800 patients (aged 40-75
years) in 132 centres in the UK and Ireland were randomly assigned either placebo
(1410 patients) or atorvastatin (1428 patients). Patients had no previous history
of cardiovascular disease and had low LDL cholesterol concentrations (around
4 millimoles per litre or less).
Average follow-up was around 4 years after study enrollment. The primary outcome
measure of the study-acute coronary heart disease events, coronary revascularization,
or stroke-was reduced by around a third among patients given atorvastatin compared
with those given placebo. Atorvastatin reduced the death rate by 27% compared
with placebo. Strokes were reduced by 48%.
Professor Colhoun comments: Atorvastatin 10 mg daily is safe and efficacious
in reducing the risk of first cardiovascular disease events, including stroke,
in patients with type 2 diabetes without high LDL-cholesterol. No justification
is available for having a particular threshold level of LDL-cholesterol as the
sole arbiter of which patients with type 2 diabetes should receive statins.
The debate about whether all people with this disorder warrant statin treatment
should now focus on whether any patients are at sufficiently low risk for this
treatment to be withheld.
In an accompanying commentary (p 641), Abhimanyu Garg (University of Texas,
USA) concludes: "While landmark trials like CARDS increase our confidence
in lipid-lowering drug therapy for prevention of coronary heart disease in patients
with type 2 diabetes, it is still prudent to assess an individual's risk-benefit
ratio before recommending long-term statin therapy. Thus more models need to
be developed, such as the UK Prospective Diabetes Study risk engine, to assess
coronary heart disease risk in patients with type 2 diabetes. For patients with
type 2 diabetes at moderate to low risk of coronary heart disease, maximal lowering
of lipids with diet, exercise, weight loss, and rigorous glycemic control must
be attempted before considering lipid-lowering drugs".
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