ESC Congress 2017 In Review -- Main Edition - 28

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higher in younger patients with LDL-C < 70 mg/dL than
in those with LDL-C 70 to < 100 mg/dL; however, there
was no event differences between these LDL-C levels in
the elderly group (Figure 1).
The probability of freedom from any late revascularisation significantly decreased in patients with LDL-C
≥ 100 mg/dL in both groups of patients. Use of statins
reduced the incidence of recurrent ACS in both the
elderly and younger groups (Figure 2).
Figure 2. Probability of Freedom From Recurrent Acute Coronary
Syndrome in Patients Who Were or Were Not Using Statins

Elderly

Figure 3. Reduction in Major Vascular Events vs Reduction in LDL-C

50%

Statin (+)
Statin (-)

P = .005
20

0
0

(Years)

Interval From Last PCI to Late Coronary Angiography
No. at risk
Using statins (+) 84
77
56
38
24
18
14
Using statins(-) 56
50
37
28
21
17
11

Younger

Probability of Freedom From
Acute Coronary Syndrome

(%)

30%

20%

10%

0%
0.5

1.0

1.5

2.0

Reduction in LDL Cholesterol (mmol/L)

LDL-C, low-density lipoprotein cholesterol; MVE, major vascular events.
Reprinted from Lancet. Baigent C et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in
14 randomised trials of statins;366:1267-78. Copyright 2005. With permission
from Elsevier.

Statin (+)
Statin (-)

P = .0010
20

0
0
No. at risk
Using statins (+) 125
Using statins(-) 39

(Years)

Interval From Last PCI to Late Coronary Angiography
120
33

101
21

65
16

47
11

23
3

15
1

ACS, acute coronary syndrome; PCI, percutaneous coronary intervention.
Reproduced with permission from A Endo, MD.

Strict control of LDL-C to < 70 mg/dL was effective
for reducing the incidence of recurrent ACS in younger
patients. However, LDL-C < 100 mg/dL might be sufficient as the target value of LDL-C-lowering therapy for
secondary prevention in elderly Japanese patients.
Jennifer G. Robinson, MD, MPH, University of Iowa,
Iowa City, Iowa, USA, discussed the benefits of statin use
for primary and secondary prevention of cardiovascular
disease (CVD) risk.

40%

-10%

Probability of Reduction in MVE Rate (±1 SE)

Probability of Freedom From
Acute Coronary Syndrome

(%)

Statins reduced CVD risk in all subgroups of patients
studied except those with class III-IV heart failure and
end-stage renal disease/haemodialysis. The reduction is in direct proportion to the magnitude of LDL-C
reduction (22% decrease in major vascular events for
every 1 mmol/L reduction in LDL-C; Figure 3) [Baigent C
et al. Lancet. 2005] with a greater reduction occurring
in younger patients [Cholesterol Treatment Trialists'
Collaborators et al. Lancet. 2012]. Twenty-six trials
have shown the safety of statins; only a slight risk of an
increase T2DM has been noted. Statin discontinuation is
associated with increased risk of myocardial infarction
and death from CVD [Nielsen SF et al. Eur Heart J. 2016].

October 2017

Statins are particularly important in patients with clinical atherosclerotic cardiovascular disease (ASCVD), LDL-C
≥ 190 mg/d, diabetes age 40 to 75 years, and ≥ 7.5%
10-year ASCVD risk. The guidelines are evolving as goals
and new lipid-lowering agents enter therapy use. Once
a patient is maximised on statin therapy, the physician
may consider adding a nonstatin (PCSK9 inhibitor) to
boost therapy benefits.
The largest absolute CVD risk reduction from adding a nonstatin is achieved in higher-risk patients with
higher LDL-C levels despite maximal statin therapy. The
focus should be on treating high-risk patients with high
LDL-C, who have the lowest numbers-needed-to-treat to
prevent one CVD event [Robinson JG. J Am Coll Cardiol.
2016]. Titration to cholesterol goals is not cost-effective
with current drug pricing. The treatment paradigm is
evolving from treat to goal, toward a focus on specific
statin benefit groups to an evaluation of the individual
patient's potential for net benefit.

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