Statin Intensity and Clinical Outcome in Patients with Stable Coronary Artery Disease and Very Low LDL-Cholesterol.
BACKGROUND
Although intensive statin therapy is recommended for high risk patients, evidence of its benefit in patients with stable coronary artery disease (CAD) and very low low-density lipoprotein-cholesterol (LDL-C) has been very rare. In this study, we investigated whether higher statin intensity reduces cardiovascular risks in this population.


METHODS
In this retrospective study, a total of 5234 patients with stable CAD were screened at three tertiary hospitals in Korea; 449 patients (mean age: 65 years, male: 69%) with LDL-C <80 mg/dL were finally analyzed. The statin intensities were classified according to the 2013 American College of Cardiology/American Heart Association guidelines. Patients who received statins equivalent to or weaker than atorvastatin 10 mg (group 1) were compared with those who took statins equivalent to or stronger than atorvastatin 20 mg (group 2). The impact of statin intensity on major adverse cardiac events (MACE) was evaluated during follow-up.


RESULTS
Group 1 and group 2 consisted of 181 patients (40.3%) and 268 patients (59.7%), respectively. The mean LDL-C level decreased to 52 and 57 mg/dL in group 1 and group 2, respectively, during follow-up. In a median follow-up of 4.5 years, patients of group 2 had a lower incidence of MACE (30 [16.6%] vs. 12 [4.5%], p <0.001), which were mostly related to a lower incidence of coronary revascularization. Cox proportional hazard analyses identified the statin intensity of group 2 (adjusted hazard ratio: 0.25, confidence interval: 0.11-0.55, p <0.001) and the baseline high-density lipoprotein-cholesterol level as independent determinants of MACE.


CONCLUSIONS
This study provides evidence that higher intensity statins are beneficial for cardiovascular outcomes in patients with stable CAD and very low LDL-C. Statins equivalent to or stronger than atorvastatin 20 mg are more effective than lower intensity statins.
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Soo Youn
SY
Lee
Division of Cardiology, Department of Internal Medicine, NHIS Ilsan Hospital, Goyang, Korea.
Seung-Jin
SJ
Oh
Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea.
Eung Ju
EJ
Kim
Department of Biostatistics and Computing, The Graduate School, Yonsei University, Seoul, Korea.
Chi-Yoon
CY
Oum
Department of Biostatistics and Computing, The Graduate School, Yonsei University, Seoul, Korea.
Sung Hwan
SH
Park
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Jaewon
J
Oh
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Jung-Sun
JS
Kim
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Byeong-Keuk
BK
Kim
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Sungha
S
Park
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Hyuk-Jae
HJ
Chang
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Geu-Ru
GR
Hong
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Young-Guk
YG
Ko
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Seok-Min
SM
Kang
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Donghoon
D
Choi
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Jong-Won
JW
Ha
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Myeong-Ki
MK
Hong
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Yangsoo
Y
Jang
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Namsik
N
Chung
Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.|Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Sang-Hak
SH
Lee
D000368:Aged; D000069059:Atorvastatin / Q000627:therapeutic use*; D008078:Cholesterol, LDL / Q000097:blood; D015243:Cholesterol, VLDL / Q000097:blood*; D003324:Coronary Artery Disease / Q000097:blood / Q000188:drug therapy*; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D016016:Proportional Hazards Models; D056910:Republic of Korea; D012189:Retrospective Studies
D008078:Cholesterol, LDL; D015243:Cholesterol, VLDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D000069059:Atorvastatin