Meet the cholesterol busters
The killer beast of heart disease is something now called acute coronary syndrome. It still eludes us, robbing more than 200,000 Americans of their lives each year. News out of Boston last week suggests that intensive treatment with one of the cholesterol-busting drugs called statins offers the best defense against this culprit.
This syndrome is not a pretty sight. Over many years, the smooth pearly linings of coronary arteries are transformed by expanding mounds of fatty plaques filled with a gruel of scar, fat, calcium, and white blood cells. The coronary crisis occurs when suddenly--and still inexplicably--this plaque (technically known as atheroma) bursts like a hot pustule. With that volcanic eruption, the atheroma's inner debris oozes out into the vessel, triggering a cascade of blood clotting in the wounded vessel. This clotting in turn starts to choke off the vessel's blood flow, and the part of the heart that has been nourished by the artery struggles for oxygen. At that point, the patient is stricken with intense and persistent chest pain, which often becomes a full-blown heart attack.
OK, enough of Cardiology 101. But these critical coronary events explain the flurry of excitement over heavy-duty statin treatment for coronary-prone patients. In these patients, treatment with the more potent statin Lipitor (80 mg of atorvastatin a day), compared with a standard 40 mg pill of another highly effective statin, Pravachol (pravastatin), brought more dramatic reduction in the level of LDL, or "bad" cholesterol, with an associated lifesaving heart benefit evident within a month. These findings came on the heels of an equally stunning report from Cleveland that the same dose of Lipitor halts the progression of atheromas and in some cases appears to shrink them, also in a matter of weeks. It does not usually work out that more of a good thing is better, but that's just what seems to be happening here.
What is especially intriguing is that intense statin therapy may be doing more than cutting bad cholesterol levels in half. It may in fact be changing the very structure of the plaque--converting it to a more stable form that is less likely to rupture. We know statins lower cholesterol, but it now appears they also can restore healthy function to cells lining the artery wall. There are many theoretical explanations for how statins might stabilize plaque, including reduction of inflammation. Statins consistently reduce the levels of a key marker of the body's inflammatory response. Whatever the mechanism, the bottom line is a previously unrecognized benefit for heart patients.
Side effects? Does all this good news mean that everyone at risk for coronary artery disease should be started on intensive statin therapy? In my mind, the answer is no. These results apply to the highest of all coronary risk groups--those who have experienced an acute coronary artery syndrome such as a heart attack. For most of these patients, the benefits of intensive treatment seem to outweigh increased side effects. But side effects are inevitable. As a general caveat, drug toxicity is almost always dose related, and side effects usually increase in direct proportion to increases in the dose of the drug. This was the case for liver toxicity for those on the higher dose of Lipitor. The rate is low at 3.3 percent, but that's three times as high as expected.
For most of the 11 million Americans who take cholesterol-reducing statins, the goal is to prevent both the development and the progression of coronary artery disease. We try this with dietary changes first, but when that doesn't work, statins can help many people get their LDL below 100 mg per deciliter, the commonly accepted guideline. In that context the statins most commonly used in the United States--Lipitor, Pravachol, Zocor (simvastatin), and Lescol (fluvastatin)--have all proved to be wonder drugs of a sort, reducing coronary risk by as much as 30 percent and mortality by 20 percent.
The rule of thumb for statin choice for most patients is still the lowest possible dose to get your cholesterol into the desired range. With a doctor's supervision and a heart-healthy diet, as little as 5 mg can sometimes do the trick. For others, who are at particularly high risk for heart attack and who need drastic cholesterol reduction, as much as 80 mg may well be needed. These drugs should be periodically reviewed and adjusted to you and your lifestyle. That medicine bottle has your name on it for a good reason.
This story appears in the March 22, 2004 print edition of U.S. News & World Report.