ISCHAEMIC HEART DISEASE

Get LDL below 2.0 mmol/l in patients with stable coronary disease? ▸

Previous trials (for example, PROVE-IT) have demonstrated that lowering low density lipoprotein (LDL) cholesterol below currently recommended values is beneficial in patients with acute coronary syndromes. In the TNT (treating to new targets) study, a total of 10 001 patients with clinically evident coronary heart disease (CHD) and LDL cholesterol < 130 mg/dl (< 3.4 mmol/l) were randomly assigned to double blind treatment and received either 10 mg or 80 mg of atorvastatin per day. Patients were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, non-fatal myocardial infarction, resuscitation after cardiac arrest, or fatal or non-fatal stroke. The mean LDL cholesterol concentrations were 77 mg/dl (2.0 mmol/l) during treatment with 80 mg of atorvastatin and 101 mg/dl (2.6 mmol/l) during treatment with 10 mg of atorvastatin. The incidence of persistent elevations in liver aminotransferase concentrations (> 3× normal) was 0.2% in the group given 10 mg of atorvastatin and 1.2% in the group given 80 mg of atorvastatin (p < 0.001). In all, 7% of the 80 mg group versus 5% of the 10 mg group stopped treatment (p < 0.001). A primary event occurred in 8.7% receiving 80 mg of atorvastatin, as compared with 10.9% receiving 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2% and a 22% relative reduction in risk (hazard ratio 0.78, 95% confidence interval (CI) 0.69 to 0.89; p < 0.001). There was no difference between the two treatment groups in overall mortality. So at present, it is worth trying to see if 80 mg atorvastatin is tolerated, since it does no harm, and may do some good. Whether this is cost effective remains to be shown.

Speciality hospitals: cherry picking easy patients? ▸

There is evidence …