PubMed · 13244172
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A PIERACH. 1955-06-25. [Circulatory prophylaxis].. https://pubmed.ncbi.nlm.nih.gov/13244172/
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BACKGROUND: There is considerable evidence that statins can reduce cardiovascular events. Currently high-risk patients are treated to a target cholesterol concentration. An alternative prescribing strategy (the 'fire-and-forget' approach) would instead deploy low-dose statins more widely. It has been suggested that for the same cost this approach might prevent more cardiovascular events. We have compared the treat-to-target and fire-and-forget statin prescribing strategies with respect to adherence and cardiovascular outcomes. METHODS: We used a population-based record-linkage database containing several data sets linked by a unique patient identifier. We identified two cohorts of patients. Patients in the treat-to-target cohort were prescribed a statin, and subsequent measurement of their cholesterol was followed by upward titration of their statin dose if necessary. Patients in the fire-and-forget cohort were prescribed a statin, but no further cholesterol measurement was observed during the follow-up period. FINDINGS: Adherence to statin treatment in patients treated to target was significantly better than in patients treated on a fire-and-forget basis (adjusted odds ratio 2.51, 95%CI 2.26-2.78). We found a lower cardiovascular disease (CVD) event rate in patients treated to target than in fire-and-forget patients (hazard ratio of CVD or cardiovascular death 0.41 (0.35-0.48) even after adjustment was made for adherence and baseline CVD risk). INTERPRETATION: Our findings suggest that adherence to statins is worse in patients treated on a fire-and-forget basis than in patients treated to a target cholesterol concentration, and that this prescribing strategy is associated with worse cardiovascular outcomes.
Although lowering low-density lipoprotein (LDL) cholesterol with statins can substantially reduce cardiovascular morbidity and mortality, many treated patients retain a residual risk for cardiovascular events. Low levels of high-density lipoprotein (HDL) cholesterol may underpin this residual risk and may represent an additional target for intervention. Several new therapies for substantially increasing HDL cholesterol levels are under investigation, including cholesteryl ester transfer protein (CETP) inhibitors, apolipoprotein A-I mimetics and recombinant HDL, liver X receptor (LXR) agonists, and peroxisome proliferator-activated receptor (PPAR) agonists. Combining new HDL cholesterol-elevating agents with existing LDL cholesterol-lowering agents may improve the cardiovascular risk reductions currently attainable.
PURPOSE OF REVIEW: Dietary supplementation with folic acid and vitamin B12 lowers blood homocysteine concentrations, but it is not known if this reduces the risk of coronary heart disease and stroke. RECENT FINDINGS: Recent evidence suggests that the maximum reduction in plasma homocysteine concentrations is obtained with 0.8 mg of folic acid and doses of 0.2 mg and 0.4 mg of folic acid are associated with about 60 and 90%, respectively, of this maximal effect. Among 12 large trials (involving a total of 52,000 participants) that are currently assessing the effects of B-vitamins on risk of coronary heart disease and stroke, results are available for four trials involving 14 000 participants. A meta-analysis of these four trials demonstrates no beneficial effects of B-vitamins on coronary heart disease (OR 0.99; 95% CI 0.88-1.10) or stroke (OR 89; 95% CI 0.76-1.05) or the combination of coronary heart disease and stroke (OR 0.98; 95% CI 0.90-1.08). The confidence intervals around the odds ratios for these completed trials are compatible with a 10% difference in risk for coronary heart disease and 20% difference for stroke associated with a 25% lower homocysteine predicted by the observational epidemiological studies. SUMMARY: The results of the ongoing homocysteine-lowering trials are required before making recommendations on the use of B-vitamins for prevention of vascular disease.