Issue 124 Item 14 Atorvastatin More Effective Than Pravastatin for Atheroscleros

Atorvastatin 80 mg/day lowered low-density lipoprotein (LDL) cholesterol levels further than did pravastatin 40 mg/day, and it also reversed atherosclerosis as reflected by reduced carotid intima-media thickness (CIMT). That, according to results of a head-to-head trial published online Sept. 23 in Circulation.

"This is the first comparison of two statin drugs in a general population that looked at more than their cholesterol-lowering abilities," lead author Allen J. Taylor, MD, director of cardiovascular research at Walter Reed Army Medical Center in Washington, D.C., says in a news release. "Previous studies found that patients in whom plaque stabilized — or stopped progressing — had the lowest risk of heart attacks and other cardiovascular disease problems. In general, past studies have shown that regression [of plaque] is uncommon."

This single-center, randomized clinical trial followed 161 patients who met National Cholesterol Education Program (NCEP) II criteria for lipid-lowering therapy. Mean age was 60 years, 71.4% were male, and 46% had known cardiovascular disease. Baseline CIMT and other clinical characteristics were similar in both groups.

After 12 months of treatment, LDL cholesterol levels were 76 +/- 23 mg/dL in the atorvastatin group (-48.5%) and 110 +/- 30 mg/dL in the pravastatin group (-27.2%; P<.001). Blinded, serial ultrasound of the far wall of the distal common carotid artery revealed progressive CIMT regression in the atorvastatin group (change in CIMT, -0.038 +/- 0.021 mm) and stable CIMT in the pravastatin group (change, 0.026 +/- 0.017 mm; P=.03). CIMT decreased in 54% of atorvastatin-treated patients and in 39% of pravastatin-treated patients.

"We need to carefully define at what point lower LDL values have the greatest benefit in lowering the risk of heart disease," Taylor says. "This study would suggest that LDL values much lower than 100 mg/dL appears better than a value of around 100."

In an accompanying editorial, Prediman K. Shah, MD, from Cedars Sinai Medical Center in Los Angeles, California, notes that several large-scale trials are underway to compare the effect of moderate versus aggressive cholesterol lowering on coronary plaque and cardiac events.

"The data provided by Taylor are of potential interest and could have significant implications for clinical practice," he writes. "However, before we conclude that more LDL-lowering means less atherosclerosis progression or clinical events, more in depth research is necessary." Circulation. Published online Sept. 23, 2002.