Current societal guidelines advise differing dosing strategies when it comes to statin usage. The European Society of Cardiology/European Atherosclerosis Society recommends targeting a low-density lipoprotein cholesterol (LDL-C) level less than 70 mg/dL or a 50% LDL-C reduction in very high risk patients while the American College of Cardiology/American Heart Association task force advises high intensity statins without a particular LDL-C target in similar populations. This study reports on the association between achieved LDL-C levels after a year on statin therapy and subsequent major adverse cardiac events (MACE) among 31,000 Israeli patients with previous ischemic heart disease aged 30 to 84 who were at least 80% adherent to their statin therapy.The primary outcome was a combination of myocardial infarction, unstable angina, stroke, percutaneous coronary intervention and coronary artery bypass grafting, or all-cause mortality over a mean 1.6 years of follow up, after adjusting for socioeconomic factors, comorbidities and medication usage. There was no difference in incidence of adverse outcomes between low (≤ 70.0 mg/dL), and moderate (70.1 – 100.0 mg/dL) LDL-C groups (hazard ratio [HR], 1.02; 95% CI, 0.97-1.07; P = .54) but a lower incidence in moderate comared to high (≥ 100.0 mg/dL) LDL-C groups (HR, 0.89; 95% CI, 0.84-0.94; P < .001). Sensitivity analyses for age cutoffs and propensity matching reached similar conclusions. In a nonlinear regression analysis, the authors found that lower LDL-C levels did correlate with reduced MACE rates, but only to a level of approximately 90 mg/dL.
Conclusions:
This study adds to a simmering debate over statin management in chronic ischemic heart disease. These findings suggest that an absolute, rather than relative LDL-C goal is appropriate but that the more severe target of ≤ 70 mg/dL may confer little advantage over a more moderate target of ≤ 100 mg/dL.
Leibowitz M, Karpati T, Cohen-Stavi CJ, Feldman BS, Hoshen M, Bitterman H, Suissa S, Balicer RD. Association Between Achieved Low-Density Lipoprotein Levels and Major Adverse Cardiac Events in Patients With Stable Ischemic Heart Disease Taking Statin Treatment. JAMA Intern Med. 2016;176:1105–9.
Patrick J Goleski, MD and James M McCabe MD