Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease
Numerous large, randomized trials have shown that the use of statins significantly reduces the likelihood of future cardiovascular events and mortality in diverse populations. In addition, recent trials have provided support that higher-intensity statins may be more effective than lower-intensity statins in reducing future cardiovascular events. In response, the 2013 American College of Cardiology/ American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommends against routine LDL-C targets and instead recommends high-intensity statin therapy use among all patients with atherosclerotic cardiovascular disease (ASCVD) under 75 years of age. This resulted in significant controversy as providers determine the best metrics for lipid performance measures and patient outcomes. Thus, this study sought to determine one-year cardiovascular mortality for VA patients (n=790,414) with ASCVD (identified from 4/13 to 4/14) by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Statin use was defined as a filled prescription in the prior six months; high-intensity statin use by ASCVD classification also was assessed, along with patient demographics and certain comorbidities (heart failure, diabetes, hypertension, and renal disease). The primary outcome was death from all causes by statin intensity.
- High-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses.
- There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins.
- Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline.
- These findings have significant implications for future lipid management practice guidelines.
- Because this was an observational study, investigators were unable to fully adjust for potential cofounders that may have impacted their results.
- Investigators were unable to determine if patients received statin treatment outside VA.
This study was supported by HSR&D. Dr. Virani is part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX; Dr. Heidenreich is part of HSR&D's Center for Innovation to Implementation (Ci2i), in Palo Alto, CA.
Rodriquez F, Maron D, Knowles J, Virani S, Lin S, and Heidenreich P. Statin Intensity and Mortality in Patients with Atherosclerotic Cardiovascular Disease: Insights from the Veterans Affairs Health System. JAMA Cardiology. November 9 2016;e-pub ahead of print.