Statin Use Following Intracerebral Hemorrhage: A Decision Analysis

Westover MB, Bianchi MT, Eckman MH, Greenberg SM
Arch Neurol. 2011 Jan 10 [Epub ahead of print]

Study Summary

For primary and secondary prevention of ischemic cardiovascular disease and stroke, statins are in widespread use and are rarely associated with serious adverse effects. However, findings from a recent study^[1] suggested that statin use may be associated with increased risk for intracerebral hemorrhage (ICH). The goal of the present study was to determine whether this potential adverse effect outweighs the cardiovascular and cerebrovascular benefits in patients with higher baseline risk for ICH because of a previous history of ICH.

Using a Markov mathematical decision model, the investigators assessed the effect of statin use on life expectancy, measured as quality-adjusted life-years, in patients with previous ICH over a range of clinical parameters, including deep vs lobar hemorrhage location, ischemic cardiac and cerebrovascular risks, and magnitude of ICH risk associated with statin use.

For many clinical parameters over a wide range of values, avoiding statins was associated with better outcomes, especially in survivors of lobar ICH who are at highest risk for ICH recurrence. Compared with statin use, avoiding statins yielded a life expectancy gain of 2.2 quality-adjusted life-years in survivors of lobar ICH without previous cardiovascular events, and this net benefit was maintained even at the lower 95% confidence interval of the relative risk of statin-associated ICH. To favor statin therapy in patients with lobar ICH and a history of cardiovascular events, the annual recurrence risk for myocardial infarction would have to be greater than 90%.

Statin therapy was predicted to increase the baseline annual probability of recurrence of lobar ICH from approximately 14% to approximately 22%. For survivors of deep ICH, avoiding statin therapy for both primary and secondary prevention also was associated with better outcomes, although by a smaller margin than in patients with lobar ICH.

References

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# posted by roodbont @ 9:59 AM 0 comments

Abstract

Atrial fibrillation is the most common sustained rhythm disturbance. Thromboembolic events related to atrial fibrillation result in significant morbidity, mortality and increases in the cost of healthcare. Anticoagulants are pivotal agents for the prevention and treatment of thromboembolic disorders. The latest American College of Cardiology/American Heart Association guidelines recommend antithrombotic therapy to prevent thromboembolism for all patients with atrial fibrillation, except those with lone atrial fibrillation or contraindications. Vitamin K antagonists were first synthesized in 1948 and for the past six decades they have been the only agents used for long-term oral anticoagulant therapy. Although these drugs are effective, they have numerous limitations, which have led to the development of newer anticoagulant therapies. The emerging oral anticoagulant agents are target selective. They have predictable pharmacokinetic and pharmacodynamic parameters and do not require routine monitoring. They are not associated with significant food and drug interactions, and can be administered in simple fixed daily or twice daily doses. This article reviews the current literature on various targets for anticoagulant therapy and newer oral anticoagulants for atrial fibrillation.

# posted by roodbont @ 9:44 AM 0 comments

Introduction

Alzheimer's disease (AD) is an irreversible, age-related neurodegenerative disorder defined by a gradual decline in understanding, memory, and ability to perform activities of daily living (ADL). It is the most prevalent type of dementia, accounting for 60% to 80% of all cases.^[1] Although no medications are available that can reverse the progress of AD, a number of drugs have limited utility in treating cognitive symptoms.

# posted by roodbont @ 7:05 AM 0 comments

Abstract (Optimale dosering geneesmiddelen hoge bloeddruk)

Control of cardiovascular (CV) risk factors, particularly hypertension, is still unsatisfactory, resulting in excess CV morbidity and mortality worldwide. CV risk is linearly associated with an increase in blood pressure (BP) values, and clinical studies have clearly demonstrated that BP lowering represents the most effective means of preventing CV events. However, while BP reduction is a fairly easy target, BP normalization is much more difficult to achieve, and adequate BP control (<140/90>

1. Introduction

Despite the great value that we attribute to scientific literature and guidelines, very often the clinical reality is far from what would be expected on the basis of shared knowledge. Atypical example is the effectiveness of hypertension treatment in the general population. It is well established that cardiovascular (CV) diseases represent the leading causes of morbidity and mortality worldwide, and that this is related to the high prevalence of CV risk factors and the failure to control them adequately.^[1,2] Essential hypertension is considered the most important CV risk factor on the basis of its very high incidence (around 50% in the adult population) and its direct, linear relationship with CV events.^[3,4]

Treatment of hypertensive patients is based on blood pressure (BP) normalization, which represents the main mechanism by which antihypertensive treatment reduces morbidity and mortality.^[5] In line with this, the 2007 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines on the management of hypertension recommend a target BP within the range of 130–139/80–89mmHg in all hypertensive patients.^[6,7]

In this review, we discuss how clinical pharmacology can be used to achieve BP goals in patients with hypertension.

PubMed searches were performed for English-language articles on the treatment of hypertension, antihypertensive therapy, combination therapy in hypertension, and clinical pharmacology of antihypertensive drugs, published from 2000 to the present. In particular, reviews, consensus statements/guidelines, and meta-analyses relevant to the above-mentioned issues were included. Earlier works, particularly those concerning the clinical pharmacology of antihypertensive drugs, were also evaluated. As a limitation, it has to be noted that this is not a systematic and exhaustive review of the published literature. This was beyond the purpose of this review, which was to merge the evidence from clinical trials, pharmacology studies, and the recommendations of international guidelines, in order to implement them in daily practice.

# posted by roodbont @ 3:15 PM 0 comments

Another Contender in the Race to Unseat Warfarin

Compared with aspirin, apixaban reduced the risk for embolic events in patients with atrial fibrillation.

A fierce competition is under way to develop a replacement for warfarin in the treatment of atrial fibrillation (AF). Dabigatran, a direct thrombin inhibitor, is approved for use in the U.S., and rivaroxaban, a factor Xa inhibitor, was noninferior to warfarin in the preliminary results of the ROCKET AF trial (JW Physicians First Watch Nov 16 2010). Now, apixaban, another factor Xa inhibitor, has been compared with aspirin in an industry-sponsored trial.

The AVERROES investigators randomized 5599 patients with AF and at least one additional risk factor for stroke to apixaban (5 mg twice daily) or aspirin (81–324 mg daily). All patients were considered unsuitable for warfarin treatment, 40% because of prior problems with the drug.

The study was terminated early because of demonstrated superiority of apixaban; mean follow-up was 1.1 years. The rate of the primary outcome — stroke or systemic embolism — was 1.6% per year in the apixaban group versus 3.7% per year in the aspirin group (hazard ratio, 0.45; P<0.001).>P=0.003).

Comment: Direct thrombin inhibitors and factor Xa inhibitors hold real promise for preventing thromboembolic events in patients with AF. Because of its long track record, warfarin will continue to play a pivotal role in AF treatment in the short term. However, in the patient considered a poor candidate for warfarin therapy, these findings indicate that apixaban could join dabigatran (and, probably, rivaroxaban) as a safe and effective alternative. Cost remains a concern; nevertheless, I believe future trials and real-world experience will eventually render warfarin obsolete.

— Mark S. Link, MD

Published in Journal Watch Cardiology February 10, 2011

Citation(s):

Connolly SJ et al. for the AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med 2011 Feb 10; [e-pub ahead of print]. (http://www.nejm.org/doi/full/10.1056/NEJMoa1007432)

# posted by roodbont @ 3:04 PM 0 comments

New Anticoagulants for Venous Thromboembolism

Apixaban bested enoxaparin for VTE prophylaxis after hip replacement, and rivaroxaban outperformed standard therapy in patients with acute deep venous thrombosis.

Heparin, low-molecular-weight heparin (LMWH), and warfarin are the anticoagulants traditionally used for the prevention and treatment of venous thromboembolism (VTE). However, these agents require parenteral administration and frequent monitoring or have a narrow therapeutic index. Apixaban and rivaroxaban are new (and not yet FDA approved) anticoagulants that are given orally and do not require regular monitoring. Researchers tested these agents in separate industry-funded trials.

In the first trial — a multinational, double-blind study of VTE prophylaxis after hip replacement surgery — 5407 patients were randomized to receive oral apixaban (2.5 mg twice daily, initiated 12–24 hours after wound closure) or the LMWH enoxaparin (40 mg subcutaneously, 12 hours before surgery and then every 24 hours postoperatively) for 35 days. Major VTE, assessed using bilateral venography, occurred in 1.1% of apixaban recipients and 3.6% of enoxaparin recipients — a significant difference for both noninferiority and superiority. Apixaban had a similar advantage over enoxaparin for the primary composite endpoint of deep venous thrombosis (DVT), nonfatal pulmonary embolism, or death from any cause (1.4% vs. 3.9%). The two groups did not differ significantly in the composite incidence of major or clinically relevant nonmajor bleeding (roughly 5% in each group).

In the second trial — an open-label trial of therapy for acute, symptomatic proximal DVT — 3449 patients were randomized to receive either oral rivaroxaban (15 mg twice daily for 3 weeks and then 20 mg once daily) or subcutaneous enoxaparin followed by a coumarin. Treatment lasted for 3, 6, or 12 months. Recurrent VTE occurred in slightly fewer rivaroxaban than standard-therapy recipients (2.1% vs. 3.0%), and the bleeding rate was identical in the two groups (8.1%). Patients who completed 6 or 12 months of therapy were then randomized to receive rivaroxaban (20 mg once daily) or placebo for an additional 6 to 12 months. Recurrent VTE occurred in significantly fewer rivaroxaban recipients than placebo recipients (1.3% vs. 7.1%; P<0.001),>

Comment: Apixaban and rivaroxaban specifically target factor Xa, which occupies a central position in the coagulation cascade. Although the agents were safe and effective in these two clinical trials, the comparisons with the older anticoagulants are open to question. In the prophylaxis study, enoxaparin was given in lower doses (40 mg daily) than those used in North America (30 mg twice daily). In the treatment trial's extension phase, anticoagulants were stopped after 6 or 12 months in the placebo group, which might be premature for some patients (as suggested by the roughly 7% incidence of VTE). Rivaroxaban's noninferiority and superiority to longer-term coumarin are unclear.

— David Green, MD, PhD

Published in Journal Watch Oncology and Hematology February 8, 2011

# posted by roodbont @ 3:01 PM 0 comments

February 9, 2011 — Isoflavones may reduce insomnia symptoms as well as hot flashes in postmenopausal women, according to the results of a controlled, double-blinded study reported in the February issue of Menopause.

"Most postmenopausal women have insomnia," write Helena Hachul, MD, PhD, from the Departamento de Psicobiologia and Ginecologia, Universidade Federal de São Paulo in Brazil, and colleagues. " Recent reports have documented that the phytohormones, isoflavones, are capable of reducing the symptoms of climacterium."

The study goal was to evaluate subjective and objective sleep parameters in postmenopausal women with insomnia and to measure changes in these parameters during treatment with isoflavones.

In this study of 38 postmenopausal women with insomnia, 1 group received 80 mg isoflavones daily for 4 months, and a second group received a placebo daily for the same period. Questionnaires and polysomnography allowed qualitative and quantitative analysis of sleep. Between-group comparisons were performed using Student's t-test and analysis of variance, and Pearson's correlation coefficient was used to test correlations.

For the isoflavone group vs the placebo group, sleep efficiency measured by polysomnography increased significantly (from 77.9% to 83.9% vs from 77.6% to 81.2%). In addition, frequency of insomnia was reduced more readily in the isoflavone group. At the beginning of the study, 94.7% of women in the placebo group had moderate or intense insomnia compared with 63.2% at the end of the study; whereas in the isoflavone group these percentages were 89.5% and 36.9%, respectively.

Isoflavones were also effective in reducing the number of hot flashes in postmenopausal women with insomnia compared with the placebo group (P = .001). This trend became apparent after 2 months of treatment, but the results became significant only after the fourth month of treatment. The intensity of hot flashes was significantly lower in the isoflavone group than in the placebo group at both evaluation points (months 2 and 4 of treatment; 1.6 vs 5.8 and 0.5 vs 3.8; P < .001).

"In postmenopausal women with insomnia, isoflavone treatment was effective in reducing insomnia symptoms, which was confirmed by increased sleep efficiency as observed by polysomnographic analysis," the study authors write.

Limitations of this study include its small sample size.

"Because sleep complaints are common during menopause," the study authors recommend that "future studies...include other sources of alternative and/or complementary treatment for insomnia in postmenopausal women."

Associação Fundo de Incentivo à Psicofarmacologia, Fundação de Amparo à Pesquisa do Estado de São Paulo, Fundação de Amparo à Pesquisa do Estado de São Paulo/Centros de Pesquisa, Inovacao e Difusao, and Conselho Nacional de Desenvolvimento Científico e Tecnol&oactue;gico supported this study. The drug was supplied by Zambon Group (both placebo and active ingredient [Fisiogen]). Three of the study authors received fellowships from Conselho Nacional de Desenvolvimento Científico e Tecnológico. The study authors have disclosed no relevant financial relationships.

Menopause. 2011;18:178-184. Abstract

# posted by roodbont @ 11:57 AM 0 comments

Discussion

In the UK, NICE seeks to guide clinicians towards clinically effective and economic choices for patient management. The NICE guidance (May 2008) on lipid modification recommends simvastatin 80 mg for secondary prevention and highlights the cost difference between a year's treatment with simvastatin 80 mg (£64.53) compared with atorvastatin 80 mg (£364.67) (9). According to the September 2010 British National Formulary, the cost difference has remained relatively unchanged, with a year's treatment with simvastatin 80 mg now costing £35.28 compared with £338.52 for atorvastatin 80 mg. However, atorvastatin is supported by more robust evidence at this dosage, particularly for secondary prevention (10,11). When atorvastatin comes off patent in the next few years, the cost difference between these medications will be significantly reduced. Until then, clinicians are faced with a conflict between prescribing for cost or for proven efficacy. This conflict is particularly challenging for clinicians treating high-risk patients, for whom the results of further cardiovascular events, loss of earnings and potential disability also have significant adverse economic effects, which may justify using a more expensive preventative agent. Unfortunately, there are no head-to-head randomised controlled studies comparing high intensity atorvastatin and simvastatin. In addition, there is little evidence about the relative merits of these agents in the setting of current clinical practice.

This study offers some comparison of high intensity atorvastatin with simvastatin in current clinical practice. Prescribers may find this 'real-life' approach useful when large-scale clinical evidence is lacking and clinical guidelines are conflicting. This audit suggests that high intensity atorvastatin is used in primary care, despite national guidelines that specifically recommend simvastatin use.^[9] In this study, patients on atorvastatin were less likely to fail to meet targets of cholesterol and LDL-C control when compared with simvastatin. This finding is consistent with other evidence supporting the efficacy of atorvastatin.^[7,10,11]

There are several limitations to this study. Importantly, it is a retrospective study with no blinding or randomisation of treatment groups. There were very few baseline lipid results available, which limits any comparison of relative efficacy of these medications on the basis of current lipid values. This outcome is because many patients had received statin treatment in some form for over a decade, predating notation in current records. However, the comparison of these agents, based on the need to discontinue therapy because of target failure remains valid, although may be affected by differences of prescribing behaviour and risk perception among prescribers. On data analysis, no statistically significant difference among prescribing behaviour and treatment effects was detected between the two general practitioners' surgeries.

A further limitation to this study involves the significantly increased usage of other lipid-lowering treatments in the atorvastatin group (p = 0.002). One must interpret the lipid concentrations with caution in light of this confounding factor, and regarding the absence of pre-treatment lipid values.

There has been recent concern about increased incidence of myositis and rhabdomyolysis in patients receiving simvastatin 80 mg.^[13,14] This study did not identify any patients with myositis or rhabdomyolysis in either treatment group. Interestingly, CK was checked in a minority of patients only. There was no statistically significant difference in tolerability between the two treatment groups. Current guidance suggests that patients with muscle-related symptoms on a statin should have CK checked.^[9]

In summary, this retrospective observational study describes routine clinical practice and highlights the conflict that prescribers face with regard to high-intensity statin use. Clinical trial evidence favours atorvastatin, whereas simvastatin remains the economic option and is favoured by national guidelines. Patients receiving atorvastatin 80 mg were significantly more likely to remain on the medication, achieving adequate cholesterol and LDL-C control, with no increase in intolerance when compared with patients treated with simvastatin 80 mg.

# posted by roodbont @ 7:33 AM 0 comments

Comment

The large NHANES III database provides a unique opportunity to evaluate in detail the relation between vitamin D and diseases in the U.S. Study limitations include the measurement of vitamin D levels only at baseline. The findings suggest that we don't yet have the final word on the relationship between vitamin D and human health and that claims that vitamin D protects against specific cancers are not necessarily supported by the facts. Dermatologists can use this information to counter people's presumption that sun exposure or tanning bed use will protect against cancer mortality; in fact, such exposure may actually increase deaths from some cancers.

# posted by roodbont @ 7:28 AM 0 comments

Abstract

The association is not clear-cut, according to an assessment of data from the Third National Health and Nutritional Examination Survey.

Introduction

Ultraviolet radiation has various deleterious effects but a positive influence on vitamin D metabolism. Dermatologists typically recommend that patients use sunscreen and take other precautions to prevent sunburn, nonmelanoma skin cancer, melanoma, and cutaneous photoaging. This practice is increasingly being scrutinized because much of the population is vitamin D deficient and because several healthful effects have been attributed to vitamin D, including a potential cancer-protection effect. To assess the association between baseline serum 25-hydroxyvitamin D levels (25[OH]D) and cancer mortality, researchers prospectively examined data on 16,819 participants in the Third National Health and Nutritional Examination Survey (NHANES III). Levels of 25(OH)D were measured once, in spring or summer in higher latitudes and in fall or winter in lower latitudes.

During a mean follow-up of 13.4 years, 884 participants died of cancer. Cancer mortality did not correlate with serum 25(OH)D in the total population or in men and women analyzed separately. However, men with 25(OH)D levels >80 nmol/L had a significantly higher cancer mortality rate than those with levels <50>

# posted by roodbont @ 7:25 AM 0 comments

From Heartwire CME

Cochrane Review Stirs Controversy Over Statins in Primary Prevention CME/CE

News Author: Sue Hughes
CME Author: Hien T. Nghiem, MD

Authors and Disclosures

CME/CE Released: 01/25/2011; Valid for credit through 01/25/2012

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CME/CE Information

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January 25, 2011 — A new Cochrane review has provoked controversy by concluding that there is not enough evidence to recommend the widespread use of statins in the primary prevention of heart disease [1].

The authors of the new Cochrane meta-analysis, led by Dr Fiona Taylor (London School of Hygiene and Tropical Medicine, UK), issued a press release questioning the benefit of statins in primary prevention and suggesting that the previous data showing benefit may have been biased by industry-funded studies. This has led to headlines in many UK newspapers saying that the drugs are being overused and that millions of people are needlessly exposing themselves to potential side effects.

This has angered researchers who have conducted other large statin meta-analyses, who say the drugs are beneficial, even in the lowest-risk individuals, and their risk of side effects is negligible. They maintain that the Cochrane reviewers have misrepresented the data, which they say could have serious negative consequences for many patients currently taking these agents.

The Cochrane authors reviewed data from 14 trials involving 34 272 patients. Outcomes in patients given statins were compared with outcomes in patients given placebos or usual care. Although results suggested that deaths were reduced on statins, the researchers say the effect is not large enough to justify the cost/effort and risk of adverse effects.

Senior author Dr Shah Ebrahim (South Asia Network for Chronic Disease, New Delhi, India) told heartwire that their review differed from others done in primary prevention in that it looked at just those at low risk, limiting the studies included to just those with populations where <10% had a previous history of cardiovascular disease (CVD).

It is probably a real effect but it means a lot of people have to be treated to gain this small benefit.

Ebrahim commented to heartwire : "If you look at the hard end points of all deaths and coronary deaths, the effects are consistent with both benefit and with the play of chance. But importantly, the absolute benefits are really rather small--1000 people have to be treated for one year to prevent one death. It is probably a real effect, but it means a lot of people have to be treated to gain this small benefit. As we don't know the harms, it seems wrong-minded to me to treat everyone with a statin. In these circumstances, lifestyle changes and stopping smoking would be far preferable."

I object to the conclusions they have drawn from their review.

But Dr Colin Baigent (Clinical Trials Service Unit, Oxford, UK) commented to heartwire : "I object to the conclusions they have drawn from their review. They say there is not good evidence of benefit, but their own data show significant reductions in deaths and cardiac events." And Baigent further objects to the Cochrane authors' suggestion that harms are not known with statins. "They didn't show any increase in adverse events in their review, but they then say the benefit is not worth the risk. That doesn't make sense."

Cochrane Results

The Cochrane review showed that in the eight trials that reported on total mortality, none of the individual trials showed strong evidence of a reduction in total mortality, but when the data were pooled, a relative risk reduction of 17% was observed with statin treatment. On combined fatal and nonfatal coronary heart disease (CHD) events, nine trials reported on this end point, with four trials showing evidence of a reduction in this combined outcome, which was maintained in the pooled analysis, with a 28% relative reduction. Seven trials reported on fatal and nonfatal stroke, and on pooled analysis, statin treatment was associated with a 22% relative reduction.

Cochrane Review: Risk Ratio of Major Events With Statins in Lower-Risk Primary-Prevention Patients

No excess in combined adverse events, cancers, or specific biochemical markers were found.

The authors conclude: "This current systematic review highlights the shortcomings in the published trials of statins for primary prevention. Selective reporting and inclusion of people with cardiovascular disease in many of the trials . . . in previous reviews of [statins'] role in primary prevention make the evidence impossible to disentangle without individual patient data."

They say that in people at high risk of cardiovascular events (>20% 10-year risk), "it is likely that the benefits of statins are greater than potential short-term harms, although long-term effects (over decades) remain unknown." They conclude: "Any decision to use statins for primary prevention should be made cautiously and in the light of an assessment of the patient's overall cardiovascular risk profile. Widespread use of statins in people at low risk of cardiovascular events--below a 1% annual all-cause mortality risk or an annual CVD event rate of below 2% observed in the control groups in the trials considered here--is not supported by the existing evidence."

Latest Oxford Meta-Analysis Not Included

The Cochrane review did not include the recent meta-analysis from the Oxford group, published late last year, which showed a clear reduction in events with statin therapy in primary-prevention patients. Baigent noted that this meta-analysis was more reliable than the Cochrane review, as the Oxford researchers used individual patient data from all the trials. "Our 2010 meta-analysis in primary prevention is substantially more complete than the Cochrane review and provides direct and overwhelmingly statistically convincing evidence of a clear reduction in events in all patient groups, right down to those at the lowest risk."

On the possible hazards of taking these drugs, Baigent says: "Statin therapy is very safe. The most serious hazard, rhabdomyolysis, is very rare, and most often seen at high doses. There is a possibility that reducing low-density lipoprotein cholesterol might increase the risk of hemorrhagic stroke, but even in primary prevention these hazards would be much smaller than the benefits, and there is no reliable evidence for other hazards mentioned by the Cochrane authors, such as depression and cognitive impairment."

It All Comes Down to Economics

Baigent says the only argument against using statins in low-risk people is economic. "The absolute benefits of statin therapy become very small when used among people at low absolute risk, so it is important that the costs of such treatment are considered when weighing how widely statins should be used. That is a government decision."

In the UK, the National Institute for Clinical Excellence [NICE] currently recommends that statins not be used for people with a CHD risk below 20% over 10 years. Ebrahim says the Cochrane conclusions are in line with this.

But Baigent argues that the benefits of statins are clear at levels far below this threshold. "Whether or not it is economic to use them in the lowest-risk individuals is not for me to say, but generic statins are now very cheap, and there is clear evidence of benefit and safety based on substantial numbers of individuals studied in large-scale trials. So, when all the relevant randomized evidence is considered, there does not seem to me to be any justification at all for the Cochrane authors' claim that the evidence is unclear on this issue."

Educational Programs Also of Little Benefit

In a separate Cochrane review [2], the same group looked at the use of "healthy heart programs" that use counseling and educational methods to encourage people to reduce their risks for developing heart disease. These risk factors include high cholesterol, excessive salt intake, high blood pressure, excess weight, a high-fat diet, smoking, diabetes, and a sedentary lifestyle. They reviewed 55 trials that aimed to reduce more than one risk factor in people without evidence of cardiovascular disease. Results showed that after a median duration of 12 months of follow-up, multiple risk-factor intervention was associated with small reductions in risk factors, including blood pressure, cholesterol, and smoking, but had little or no impact on the risk of coronary heart disease mortality or morbidity. They conclude: "The methods of attempting behavior change in the general population are limited and do not appear to be effective. Different approaches to behavior change are needed and should be tested empirically before being widely promoted, particularly in developing countries where cardiovascular disease rates are rising."

In an accompanying editorial [3], Dr Carl Heneghan (University of Oxford, UK) suggests an alternative approach for policy is to focus on populationwide prevention. He reports that "legislating for smoke-free public spaces, redesigning public spaces to improve exercise, or reducing daily dietary salt intake prove generally effective and can be cost-saving interventions. Given the scale of the worldwide CVD problem, large-scale commissioned studies of multiple risk-factor interventions are urgently required."

References

1. Taylor F, Ward K, Moore THM, et al. Statins for the primary prevention of cardiovascular disease - Available here.Cochrane Database Syst Rev 2011; 1 (CD004816).
2. Ebrahim S, Taylor F, Ward K et al. Multiple risk factor interventions for primary prevention of coronary heart disease - Available here. Cochrane Database Syst Rev 2011; 1 (CD001561).
3. Heneghan C. Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease [editorial].Cochrane Libr2011 (January 19, 2011). Available here.

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