Is intensive LDL-cholesterol lowering beneficial and safe? Review article

Abstract

Statins have been in clinical use for almost two decades. Lowering of LDL cholesterol with standard statin regimens reduces the risk of occlusive vascular events in a wide range of individuals. A recent metaanalysis of individual participant data from 26 randomized trials investigating standard statin therapy vs placebo or standard versus intensive statin therapy addressed the question whether further reduction in LDL cholesterol would result in additional clinical benefit. It was shown that more intensive therapy further lowered LDL level by about 0.5 mmol/l thus producing further reductions in the incidence of major vascular events by about a sixth. The reductions in risk per 1 mmol/l of LDL cholesterol reduction were similar in all types of trials and independent of the baseline LDL level. Clinical benefit was observed even in those with very low baseline LDL concentrations. Intensive statin therapy was not associated with increased non-vascular mortality and site-specific cancer incidence. Current guidelines recommend therapeutic goals regarding LDL lowering depending on the baseline cardiovascular risk profile. In high risk population LDL should be reduced to less than 100 mg/dl or optionally to below 70 mg/dl. The results of the metaanalysis suggest further lowering of LDL cholesterol in patients who have already achieved those targets. This can be safely achieved by the use of new, potent statins (eg. atorvastatin 80 mg or rosuvastatin 20 mg daily).