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What Is the Best Approach to Lipid Management?

In a simulation study, basing statin treatment on overall cardiovascular risk produced better outcomes than basing treatment on target LDL levels.

The benefits of using statins to lower elevated cholesterol levels are unquestioned; however, the optimal strategy for initiating and maintaining statin treatment is debated. The most common practice is to titrate the statin dose to achieve a desired LDL level ("targeted" treatment). An alternative approach is to base a fixed dose on the patient's estimated risk for coronary artery disease ("tailored" treatment). In a population-level simulation study, Hayward and colleagues used NHANES data collected between 1988 and 1994 to compare outcomes of targeted and tailored statin treatments.

Participants (age range, 30–75) had no history of acute MI. Each person's untreated risk for fatal and nonfatal coronary events was calculated using sex-specific models based on the Framingham Heart Study. Targeted treatment followed NCEP III guidelines, and two different escalation approaches ("standard" and "intensive") were modeled. In the tailored-treatment strategy, individuals with 5-year risks for coronary events of 5% through 15% received simvastatin (40 mg), and those with risks higher than 15% received atorvastatin (40 mg). Tailored treatment was not based on LDL measures.

Compared with standard targeted treatment, intensive targeted treatment resulted in 15 million more persons treated and saved 570,000 more quality-adjusted life-years over 5 years. Tailored treatment resulted in a similar number of persons treated as did intensive targeted treatment but saved 520,000 more quality-adjusted life-years and required fewer high-potency statin regimens. Sensitivity analysis found no instance in which targeted treatment produced better results than tailored treatment.

Comment: In this simulation, prescribing a fixed statin dose based on the estimated risk for CAD was preferable to escalating the statin dose based on LDL level. The tailored approach does not require monitoring of LDL levels and results in fewer patients taking high-potency statins than the targeted approach. This model deserves to be validated in a randomized trial; however, I doubt that the impetus for such a study exists. Moreover, regardless of the physician's approach to statin treatment, patient adherence to treatment remains the key to success.

— Joel M. Gore, MD

Published in Journal Watch Cardiology January 27, 2010

Citation(s):

Hayward RA et al. Optimizing statin treatment for primary prevention of coronary artery disease. Ann Intern Med 2010 Jan 19; 152:69.

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