Publication
of the landmark Heart Protection Study (HPS), the world largest statin study is
fuelling calls for the guidelines on cholesterol lowering to be emphasize a
strategy of treating high risk, not high cholesterol. The results appear in the
July issue of Lancet. [
Methods:
20,536
UK adults (aged 40-80 years) with coronary disease, other occlusive arterial
disease, or diabetes were randomly allocated to receive 40 mg simvastatin daily
(average compliance: 85%) or matching placebo. Analyses are of the first
occurrence of particular events.
Results &
Comments:
The
HPS investigators- including Profs Rory Collin and Peter Sleight and Dr Jane
Armitage commended, “HPS is the most important study we have ever been
associated with. Guidelines, including those from the US National Cholesterol
Education Program, will be changed.”
The
change will not be easy, though, she noted: “It still requires a conceptual shift that normal (cholesterol) is not
normal ... and that's going to be
hard for doctors because it requires a shift in the way we think. We're very
used to measuring something and responding to a measurement and I think it's
going to take years to actually get people out of that mindset. We've been
working towards it with blood pressure and we've now got to move towards it with
cholesterol.”
All
the experts at the press conference agreed, however, that doctors should start
using statins more widely immediately, and not wait for guidelines to change. Possibly the most important message from HPS is that western concepts of
“normal” cholesterol levels are way out of line.
“The
message is simple: treat risk, not cholesterol level,” Collins said. HPS - a
mixed primary/secondary prevention study aimed at “real world” patients -
showed that taking 40mg of simvastatin daily over five years, compared to
placebo, reduced myocardial infarctions and strokes by about a third among
patients aged 40 or over who were deemed to be at “high risk”.
Dr
Salim Yusuf (McMaster University, Ontario, Canada) says the past 25 years have
seen the establishment of aspirin, beta blockers, ACE-inhibitors, and
lipid-lowering therapies to prevent the risk of future vascular events by about
a quarter each, in high-risk patients. “The benefits of each intervention
appear to be largely independent, so that when used together in appropriate
patients, it is reasonable to expect that about two-thirds to three-quarter of
future vascular events could be prevented.”
