Statins Beneficial in Diabetes Patients With ACS

The data, however, highlight the need for additional strategies
in this high-risk group of patients.

Results from a subgroup analysis of the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE IT) TIMI 22 trial show significant reductions in acute coronary events among acute coronary syndrome (ACS) patients with diabetes who are treated with intensive statin therapy.

The data, recently published in the European Heart Journal, reveal that intensive lipid lowering among this patient population is indeed beneficial. Christopher P. Cannon, MD, from the cardiovascular division at Brigham and Women’s Hospital and Harvard Medical School, and colleagues, wrote that the impact of intensive lipid lowering with statins in ACS patients with diabetes has not been well characterized.

The trial tested standard therapy with pravastatin
40 mg (Pravachol; Bristol-Myers Squibb, New York, NY) versus intensive statin therapy with atorvastatin (Lipitor; Pfizer, New York, NY) among patients treated early in the post-ACS period, according to the report. Dr. Cannon and colleagues compared outcomes between patients with diabetes (n=978) and those without (n=3,184). Patients with diabetes were identified by history, fasting plasma glucose ≥126 mg/dL or Hb1Ac >7%.

The investigators found that the rate of acute coronary events, including death, myocardial infarction (MI) and unstable angina requiring rehospitalization among patients on intensive versus standard therapy was much higher in patients with diabetes, (21.1% vs 26.6%, HR=0.75, P=.03) than in those without (14.0% vs 18.0%, HR=0.76, P=.002). Although the relative risk reduction with intensive therapy was nearly the same in both groups, the absolute risk reduction was larger in patients with diabetes (5.5%) than in those without diabetes (4.0%).

Despite intensive lipid-lowering intervention, however, the investigators noted that the majority of patients with diabetes did not reach the dual goal of LDL cholesterol <70 mg/dL and high-sensitivity C-reactive protein <2 mg/L.

Mean LDL was reduced by 44% from baseline among patients with diabetes assigned to atorvastatin versus an 18% reduction among pravastatin-assigned patients.

“Improved clinical outcomes were seen in patients with and without diabetes, but since [patients with diabetes] were at higher risk, more acute cardiac events (death, MI or unstable angina) were prevented with intensive therapy in those with diabetes (55 vs 40 per 1,000 patients treated without diabetes),” Dr. Cannon wrote.

Current clinical practice guidelines do not agree on target LDL numbers in patients with diabetes, they said. While the American College of Physicians supports statin therapy among patients with type 2 diabetes, it does not specify an LDL goal. The American Diabetes Association suggests a target LDL of <100 mg/dL, and the National Cholesterol Education Program Adult Treatment Panel III Guidelines advocates an LDL of <100 mg/dL with the option to treat to <70 mg/dL in patients with diabetes.

“In our analysis, the LDL in both intensive and standard arms at ‘baseline’ was already in this range (<100 mg/dL), yet further LDL led to further reduction in cardiovascular events,” Dr. Cannon and colleagues said. “In view of the very high event rate in patients with diabetes who did not achieve the dual goal even on intensive therapy, additional lifestyle (or drug) strategies are warranted to attain this goal.”

Christopher P. Cannon, MD, is in the cardiovascular division at Brigham and Women’s Hospital and the Harvard Medical School. Dr. Cannon received research grant support from Accumetrics, Bristol-Myers Squibb, Glaxo SmithKline, Merck, Pfizer, Sanofi-Aventis and Schering Plough. He may be reached at cpcannon@partners.org.

Ahmed S, Cannon CP, Murphy SA, Braunwald E. Acute coronary syndromes and diabetes: is intensive lipid lowering beneficial? Results of the PROVE IT-TIMI 22 trial. Eur Heart J. 2006;27:2323-2329.
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