Hypercholesterolemia in men and women of various age. Part II. The problem of efficacy and safety of statins

Hypocholesterinemic drugs from the statins class are effective means of primary and secondary prevention of ischemic heart disease (IHD) in middle aged men who comprised predominant majority of patients participating in randomized controlled trials (RCT). Proofs of favorable influence of statins on origination and progression of IHD in women and elderly people are less convincing. In majority of RCTs of therapy with statins results of which were analyzed separately for men and women no lowering of rates of coronary events were found among women and people older then 65 - 70 years. Moreover in some trials increases of all cause mortality were observed in statin treated patients at the account of deaths from non-cardiovascular causes (cancer deaths in particular). In the PROSPER trial pravastatin not only turned out useless in men and women aged 70 - 82 years, but significantly increased rate of breast cancer. In ALLHAT-LLT in patients aged 65 years and older and in women pravastatin lowered neither total number of nonfatal myocardial infarctions and IHD deaths, nor total mortality. In SPARCL and TNT in which efficacy and safety of high dose statin (e.g. atorvastatin 80 mg/day) was assessed there occurred augmentation of risk of hemorrhagic stroke and mortality from noncardiovascular causes including cancer and infections. One of meta-analyses of RCTs revealed significant increase in breast cancer risk associated with treatment with statins, in another meta-analysis more close relationship was noted between statins and development of cancer in elderly patients. Thus the problem of efficacy and safety of long-term therapy with statins remains open and requires further investigation.     

Translating evidence into practice: use of statins in real-world patients with heart failure

Heart failure is a common and serious disorder affecting more than 5 million patients in the United States. Although clinical trials have shown that several therapies improve outcomes, translation of evidence into practice is imperfect. This "quality chasm" ultimately leads to lost opportunities for decreasing morbidity and mortality. As more evidence is gathered for statins in heart failure, it will be important to continuously assess implementation of statins in eligible heart failure patients, as well as to identify opportunities for and barriers to improvement. This article reviews the conceptual basis for driving evidence-based medicine by focusing on quality of care for heart failure patients.     

他汀类药物的评价与合理应用

血脂异常是心脑血管疾病的危险因素。在他汀类药物问世之前 ,使用其他调脂药物进行的临床研究已显示 ,调脂治疗在改善血脂异常的同时能有效降低冠心病的发病率及病死率 ,但尚未肯定其对总病死率的降低作用 ,甚至有增加的报道。因此 ,人们曾怀疑调脂治疗是否会增加心血管疾病以外的其他死亡。近 10多年来 ,应用他汀类药物进行的一系列大型的对冠心病一级、二级预防试验取得了举世瞩目的成就 ,一致证实了应用他汀类药物调整血脂的同时 ,还能有效降低冠心病事件及病死率 ,降低对经皮冠状动脉 (冠脉 )腔内成形术及主动脉冠脉旁路移植术的需求 ,…     

他汀类药物早期强化治疗在急性冠脉综合征中的价值

负荷量他汀强化治疗已是冠心病一级预防和二级预防中不可缺少的重要手段,可明显降低心血管疾病的患病率和死亡率,改善接受介入治疗（percutaneous coronary intervention,PCI）的急性冠脉综合征患者术后心肌梗死和心血管危险事件的发生率[1].     

The use of statins and lung function in current and former smokers

BACKGROUND: Smokers are affected by a variety of inflammatory diseases, including COPD. Statins, 3-hydroxy-3-methyl-glutaryl-coenzyme-A reductase inhibitors, are used for their lipid-lowering characteristics but also appear to have antiinflammatory and immunomodulatory activities. We assessed their ability to preserve lung function in current and former smokers. METHODS: All smokers and ex-smokers seen at the Oklahoma City VA hospital in 2005 with abnormal baseline spirometry findings and two or more pulmonary function tests done 6 months apart were classified into obstructive and restrictive groups based on the initial PFT result. Statin use, annual decline in FEV(1) and FVC, and need for respiratory-related urgent care (emergency department or inpatient) were compared. RESULTS: Approximately one half, 215 of 418 patients, were receiving a statin. Compared to the control group, statin users had a lower decline in FEV(1) (- 0.005 +/- 0.20 L/yr vs 0.085 +/- 0.17 L/yr, p < 0.0001) and FVC (- 0.046 +/- 0.45 L/yr vs 0.135 +/- 0.32 L/yr, p < 0.0001) [mean +/- SD]. This difference remained significant irrespective of whether the patient had obstructive (n = 319), or restrictive (n = 99) disease, and regardless of whether the patient continued or stopped smoking. In patients with an obstructive spirometry finding, we found a lower incidence of respiratory-related urgent care in favor of the statin group (0.12 +/- 0.29 patient-years vs 0.19 +/- 0.32/patient-years; p = 0.02). CONCLUSION: In smokers and former smokers, statins are associated with a slower decline in pulmonary function, independent of the underlying lung disease. Clinical implication: Prospective, randomized trials are needed to study the effect of statins on lung function.     

Early use of statins in acute coronary syndromes

This review examines the use of statin medications early in the clinical course of acute coronary syndrome (ACS). Available data demonstrate that there are clear clinical benefits to this practice. Numerous previous studies have documented the primary and secondary benefits of statins in the prevention of coronary events. Recent trials show that when statins are used during hospital admissions for ACS, patients experience decreased recurrent myocardial infarction, lower death rates, and fewer repeat hospitalizations for ischemia or revascularization. Several studies suggest that the positive effects of statins on plaque stabilization, inflammation, thrombosis, and endothelial function may be independent of lipid levels. There is also an emerging view that beneficial lipid-lowering with statins in high-risk patients has no lower limit. This information suggests that all patients admitted for ACS should be treated with statins, regardless of cholesterol levels.     

Hypercholesterolemia. The NCEP Adult Treatment Panel III Guidelines

Coronary heart disease (CHD) is a significant cause of morbidity and mortality in older patients. Therefore, its treatment and prevention is vital to improving the length and quality of life for the geriatric population at large. Clinical trial data have demonstrated that patients age 65 and older derive the same benefit from blood cholesterol reduction as younger adults. As a result, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) recommends appropriate therapeutic lifestyle changes and drug therapy for older individuals with established CHD or for those at high risk for CHD. Drug therapy in this population, while safe, requires careful monitoring and dose adjustment due to potentially altered drug metabolism and concomitant medications. These factors lead to use of lower starting doses of lipid-lowering medications in older patients. Prudent individualized evaluation and customized therapy provide optimal cardiovascular outcomes.     

Early use of statins in acute coronary syndromes

This review examines the use of HMG-CoA reductase inhibitor (statin) medications early in the clinical course of acute coronary syndrome. Available data demonstrate that there are clear clinical benefits to this practice. Numerous previous studies have documented the primary and secondary benefits of statins in the prevention of coronary events. Recent trials show that when statins are used during hospital admissions for acute coronary syndrome (ACS), patients experience decreased recurrent myocardial infarction, lower death rates, and fewer repeat hospitalizations for ischemia or revascularization. Several studies suggest that the positive effects of statins on plaque stabilization, inflammation, thrombosis, and endothelial function may be independent of lipid levels. There is also an emerging view that beneficial lipid-lowering with statins in high-risk patients has no lower limit. This information suggests that all patients admitted for ACS should be treated with statins, regardless of cholesterol levels.     

Hypercholesterolemia. Prevention and control

In the last few years, public concern about cholesterol has become a national preoccupation. Concerned consumers increasingly direct their questions about cholesterol to the nurses with whom they come in contact. Nurses in any setting who are knowledgeable about cholesterol are in an ideal position to teach current, accurate, potentially life-saving information about it. Nurses everywhere have a responsibility to assist consumers to achieve the goals of the National Cholesterol Education Program (NCEP) panel of experts within the next few years. This article describes the prevention and control of hypercholesterolemia through dietary and life-style changes. Drug therapy for control of hypercholesterolemia is discussed. Specific nursing interventions that are designed to assist people to achieve the NCEP goals are outlined.     

Vascular pleiotropy of statins: Clinical evidence and biochemical mechanisms

The ability of statins to lower serum cholesterol and reduce coronary heart disease endpoints has confirmed portions of the lipid hypothesis. However, the time to benefit and increased benefit in overlapping populations have suggested that nonlipid or pleiotropic effects of statins may be present. The apparent benefit of statins in cerebrovascular disease may imply a similar final common pathway among the diverse mechanisms of vascular diseases. Statins’ inhibition of isoprenoid intermediates may modify GTP binding proteins such as Rho. The augmentation of collateral blood flow downstream of activated plaque through endothelial cell nitric oxide synthase may be the biochemical basis of statins’ vascular pleiotropy. Eventual clinical paradigms of statin use may include higher doses to enhance pleiotropic effects and treatment, even when lipid markers are within guidelines.     

他汀类药物与糖尿病风险的临床证据解读

许多他汀类药物的大型临床试验均证实了其对心脑血管事件的预防作用,他汀类药物已成为心脑血管事件一级和二级预防的基石。但是,近年一些临床研究显示,他汀类药物的使用与新发糖尿病危险增加相关。由于糖尿病本身也是心脑血管疾病的一个危险因素,