Session number: 1003
Abstract title: Effectivness of Statins to Reduce Clinical Events in Adults with CHD
Author(s):
TJ Wilt - Mpls VAMC/Center for Chronic Disease Outcomes Research
HB Rubins - Mpls VAMC/Center for Chronic Disease Outcomes Research
R MacDonald - Mpls VAMC/Center for Chronic Disease Outcomes Research
I Rutks - Mpls VAMC/Center for Chronic Disease Outcomes Research
D Nelson - Mpls VAMC/Center for Chronic Disease Outcomes Research
S Pineros - Ischemic Heart Disease Quality Enhancement Research Initiative (IHD-QUERI)
G Larsen - Portland VAMC
M Ho - Denver VAMC
A McCall - Portland VAMC
A Sales - Ischemic Heart Disease Quality Enhancement Research Initiative (IHD-QUERI)
Objectives: To conduct a systematic review and meta-analysis to determine at what LDL-c level does initiation or an increase in the dose of an HMG Co-A reductase inhibitor (statin) reduce mortality, CHD events, or procedure utilization; what LDL-c level should be achieved to reduce future CHD events or procedure utilization; and the magnitude of treatment effectiveness.
Methods: The systematic review and meta-analysis protocol was prospectively designed and followed QUOROM Guidelines. Studies were included if they enrolled adults with CHD, included a minimum of 100 subjects per arm, involved a statin, reported LDL-c and predefined clinical outcomes; and randomly assigned participants to treatment or control. Data were extracted onto standardized, validated forms. Meta-analyses were performed using a random effects model following the methodology of DerSimonian and Laird. Meta-regression assessed the relationship between statin use, baseline LDL-c, and mortality/CHD events.
Results: Pooled analysis of 17 RCT involved 27,500 subjects (mean age = 60 years, Caucasian = 90%, female = 19%). Statins reduced baseline LDL-c 20-40% (mean baseline LDL-c = 151 mg/dL, range = 130-198). Statins provided a 21-28% relative reduction in all-cause mortality, fatal and nonfatal CHD events, and CHD procedure utilization. Results were similar in women and elderly. No trials evaluated baseline LDL-c below 130 mg/dL. There were no placebo controlled RCT in chronic CHD to determine if lowering LDL-c to below 100 mg/dL, compared with LDL-c lowering between 100-130 mg/dL, reduces CHD events. Meta-regression indicated that absolute and relative risk reduction decreased at lower baseline LDL-c and no reductions in mortality/CHD events occurred at baseline LDL-c below 120 mg/dL.
Conclusions: Statins reduce LDL-c and decrease mortality, CHD events and procedure utilization in adults with CHD and LDL-c > 130 mg/dL. There is no RCT evidence demonstrating that initiating or increasing doses of statins decreases clinical outcomes for LDL-c below 130 mg/dL. Meta-regression suggests that initiating statins at LDL-c > 120 mg/dL reduces the combined outcome of CHD death or nonfatal MI. There is no RCT evidence to determine if lowering LDL-c to below 100 mg/dL, compared to below 130 mg/dL, is beneficial.
Impact statement: These results can assist the VA:QUERI-IHD develop evidence-based CHD lipid treatment guidelines.