Secondary Prevention of Cardiovascular Disease: The Role of HMG-CoA Reductase Inhibitors

Abstract.

There continues to be considerable debate about the wisdom of drug-induced cholesterol lowering in the primary prevention of coronary artery disease (CAD). There is no debate, however, that in patients with established disease, cholesterol treatment is of prime importance. Cohort studies demonstrate that LDL and HDL continue to be important predictors of both morbidity and mortality in patients with established coronary disease. Data from secondary prevention trials indicate that all-cause and CAD mortality are decreased in patients whose cholesterols are lowered. Evidence from regression studies indicates that coronary atherosclerosis can be arrested and perhaps reversed by aggressive lipid treatment. Finally, cost-benefit analyses demonstrate actual cost savings by vigorous cholesterol interventions. Current guidelines, however, do not sufficiently emphasize the importance of treatment in patients with CAD. Animal and human regression studies indicate that a desirable LDL cholesterol is one less than 100 mg/dl (2.6 meq/L). It is unlikely that such levels can be routinely obtained in most patients with hypercholesterolemia without the use of HMG-CoA reductase inhibitors. Properly used, HMG-CoA reductase inhibitors can become agents not only of prevention but also for reversal of established coronary disease.