Association Between Achieved Low-Density Lipoprotein Levels and Major Adverse Cardiac Events in Patients With Stable Ischemic Heart Disease Taking Statin Treatment

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

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