title: A six-month, multicenter, open-label, noncomparative, prospective, observational study of the efficacy and tolerability of atorvastatin in the primary care setting(estudio del control de las hiperlipidemiasen atención primaria): the cheap study.
abstract: BACKGROUND
  A close relationship exists between high levels of total cholesterol (TC) (particularly low-density lipoprotein cholesterol [LDL-C]) and low levels of high-density lipoprotein cholesterol (HDL-C), which is associated with an increased risk for arteriosclerosis and cardiovascular disease (CVD). Evidence shows that atorvastatin produces significantly greater reductions in LDL-C and TC than other hydroxymethylglutaryl-coenzyme A reductase inhibitors. However, the results achieved in clinical studies could be different from those found in general clinical practice, where patient follow-up is less thorough and poorer compliance may reduce the effectiveness of the lipid-lowering therapy.
  
  
  OBJECTIVE
  The aim of this study was to assess the effectiveness of atorvastatin in achieving the LDL-C levels recommended by several Spanish scientific societies, as well as its tolerability in standard clinical use.
  
  
  METHODS
  This 6-month, open-label, noncomparative, prospective, observational study was conducted in 1351 primary care centers in Spain. All patients were aged 18 to 80 years and had primary hypercholesterolemia (TC >200 mg/dL and triglycerides [TG] <lt;200 mg/dL) or combined hyperlipidemia (TC >200 mg/dL and fasting TG 200-400 mg/dL). All patients also had LDL-C levels higher than those established by the Spanish Society of Arteriosclerosis (Sociedad Española de Arteriosclerosis [SEA]) according to baseline cardiovascular risk and previous use of lipid-lowering therapy (for patients with low, moderate, or high cardiovascular risk, the recommended LDL-C goals are ≤175 mg/dL, ≤155 mg/dL, and ≤135 mg/dL, respectively; for patients with CVD, the LDL-C goal is ≤100 mg/dL). None of the patients had creatine kinase activity ≥540 U/L or alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels ≥60 U/L. Study visits occurred at months 0, 2, and 6 of treatment. Patients received atorvastatin calcium 10 mg/d for 2 months. The dosage was then doubled to 20 mg/d in patients who did not achieve the SEA LDL-C goal and also in those patients whose primary care physicians (PCPs) deemed this higher dosage necessary; this dosage was continued for at least 4 additional months, to complete at least a 6-month course of treatment. The percentage of patients who achieved their goals was used to measure atorvastatin effectiveness. Percentages of change in LDL-C, TC, TG, and HDL-C from baseline to the final study visit also were used as measures of effectiveness. The incidence of adverse events (AEs) per 10,000 patient-months was used for the primary tolerability analysis. A secondary tolerability analysis was performed in all patients treated with atorvastatin who had some recorded follow-up, regardless of whether the patient met inclusion criteria. Information was obtained from data recorded in the case-report forms.
  
  
  RESULTS
  A total of 5317 outpatients (2715 women, 2598 men, 4 sex unknown; mean [SD] age, 58.7 [10.5] years) were enrolled. Among patients receiving known dosages of atorvastatin, 1580 of 4033 (39.2%) and 2378 of 3585 (66.3%) patients met the SEA LDL-C goal after 2 and 6 months of therapy, respectively (P<lt;0.001 for 2 months vs 6 months). Among the patients with low and moderate cardiovascular risk, 85.8% achieved the SEA LDL-C goal compared with 64.4% of high-risk patients (P<lt;0.001). Mean LDL-C decreased by 36.2%. Mean reductions in TC and TG levels were 26.9% and 19.2%, respectively. Mean HDL-C increased 17.0%. One hundred forty-eight patients (2.9%) experienced at least 1 AE and 25 (0.5%) had serious AEs. Eighty-nine patients had 134 AEs considered treatment related. Two of the serious AEs (phlebitis and a severe increase in ALT and AST activity) were considered treatment related. A total of 98.5% and 97.2% of PCPs and patients, respectively, reported excellent or good tolerability with atorvastatin.
  
  
  CONCLUSIONS
  In this study population, the use of atorvastatin in the primary care setting was associated with high achievement rates of the SEA LDL-C goals and with a substantial decrease in TG levels. In addition, a considerable increase in HDL-C levels occurred. Tolerability with atorvastatin was reported to be excellent or good by most of the patients and PCPs. The incidence of serious AEs was minimal, as reported by both patients and PCPs.
authors.affiliation: Department of Clinical Chemistry, Jimenez Díaz Foundation, Madrid, Spain.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Gómez-Gerique
authors.affiliation: Department of Internal Medicine, Gregorio Marañón Hospital, Madrid, Spain.
authors.forename: Luis A
authors.initials: LA
authors.lastname: Alvarez-Sala
authors.affiliation: Medical Unit, Pfizer, S.A., Madrid, Spain.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Armada
authors.affiliation: Medical Unit, Pfizer, S.A., Madrid, Spain.
authors.forename: Isabel
authors.initials: I
authors.lastname: Fernández-Arias
authors.affiliation: Medical Unit, Pfizer, S.A., Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Martinez
authors.affiliation: Medical Unit, Pfizer, S.A., Madrid, Spain.
authors.forename: Gonzalo
authors.initials: G
authors.lastname: Hernández
keywords: atorvastatin; hypercholesterolemia; hyperlipidemia; primary care