Study Review Questions Aggressive Cholesterol Treatment

| August 7, 2012

The Cholesterol Treatment Trialists (CTT) is a UK-based collaboration of doctors and researchers who, on the whole, push for aggressive treatment of cholesterol to low levels. I don’t think it would misrepresent the CTT’s view to say that, as far as supposedly unhealthy ‘LDL-cholesterol’ levels are concerned, ‘the lower the better’. However, it has been pointed out in the past, that there are at least some conflicts of interest within the CTT group that might bias its opinion. See here for a previous blog post relevant to this issue.

Some doctors and researchers have been critical of the CTT’s stance. Recently, for instance, a group from the Mike Rosenbloom Laboratory for Cardiovascular Research, at McGill University Health Centre in Quebec, Canada, published an article in the Journal of Clinical Lipidology, which raised a number of issues regarding the evidence for the CTT’s stance [1].

The Canadian group focused on five studies [2-6] which, earlier this year, the CTT used to support its recommendations for intensive statin therapy. These five studies were cited as part of a larger review published earlier this year in the Lancet medical journal [7]. According to the Canadian group, the body of evidence used by the CTT has a number of weaknesses and inconsistencies, which have not been previously brought to the fore and should be recognised.

One major objection is that some of the studies compared very different doses of statins e.g. 10 mg versus 80 mg of atorvastatin (Lipitor). However, in clinical practice, particularly in people with a previous history of cardiovascular disease, rarely will a dose of 10 mg of atorvastatin be used. It is much more common for an individual to be, say, on a dose of 40 mg, and the question might then be whether or not to raise the dose to 80 mg per day. In other words, in the real world, doctors will usually be debating whether or not to use moderate or high doses of statins, and these decisions are not properly informed by data in which high dosages have been compared with low (and often unrealistic) dosages.

Another problem cited by the Canadian group is that in many of the studies used by the CTT, individuals had relatively high levels of LDL-cholesterol. We cannot tell from this data what the impact would be on individuals with normal or lower-than-normal cholesterol levels. So, it is not right to assume that the benefits seen in people with higher cholesterol will extend into this group, as the CTT has done.

The Canadian group goes on to estimate the likely benefit of increasing atorvastatin dosing from 40 to 80 mg. They calculate that the likely reduction in ‘clinical events’ such as heart attacks and strokes would be about 2 per cent (small). Of course, as they point out, doubling the dosage of the statin drug will likely bring with it a significant increase in the number of adverse effects including muscle pain, fatigue, liver damage and kidney damage. They conclude: “Accordingly, whether net benefit would be demonstrable cannot be assumed. It follows that definitive evidence supporting maximal lowering of LDL-C or maximal dose of statins is still lacking and guidelines, if they are to be evidence-based, should acknowledge this uncertainty.”

It’s good to see, I think, that some doctors and researchers are prepared to question the general advice given to us to drive cholesterol to ever-lower levels.

Here’s to a healthy heart

Dr John Briffa
Editor
for The Cholesterol Truth



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References:

1. Sniderman A, et al. Is lower and lower better and better? A re-evaluation of the evidence from the Cholesterol Treatment Trialists’ Collaboration meta-analysis for low-density lipoprotein lowering. J Clin Lipidol 2012;6(4):303-9

2. Cannon CP, et al. Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes. N Engl J Med. 2004;350:1495–504

3. La Rosa JC, et al. Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease. N Engl J Med. 2005;352:1425–35

4. Pedersen TR, et al. High-Dose Atorvastatin vs Usual-Dose Simvastatin for Secondary Prevention After Myocardial Infarction: The IDEAL Study: A Randomized Controlled Trial. JAMA. 2005;294:2437–45

5. de Lemos JA, et al. Early Intensive vs a Delayed Conservative Simvastatin Strategy in Patients With Acute Coronary Syndromes: Phase Z of the A to Z Trial. JAMA. 2004;292:1307–16

6. Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group. Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12 064 survivors of myocardial infarction: a double-blind randomised trial. Lancet. 2010;376:1658–69

7. Cholesterol Treatment Trialists’ (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. The Lancet epub 17th May 2012

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Category: The Great Cholesterol Con

Comments (1)

Testimonials are based on the personal experience of individuals. Results are not typical and the potential benefits of taking any drug or supplement may vary depending on your individual needs and health requirements. Please consult your GP before making any changes to your medical regimen.

  1. Winnifred Armstrong says:

    A local pharmacist just back from a statin seminar learned that the
    NNT, the number needed to treat, for statins is shocking.
    For men aged 50-70, 65 men need to take a statin drug every day for five years in order to prevent one heart attack in the group. That challenges any idea that statins are effective in doing what patients expect them to do ie. prevent heart attacks. Food for thought.

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