Is a strategy of treat-to-target statin dosing noninferior to high-intensity dosing for adults with coronary artery disease?
This study found that statin dosing based on a treat-to-target LDL level of 50 mg/dL to 70 mg/dL is noninferior to a high-intensity strategy for reducing adverse events in adults with established CAD. Although the authors see this as an advantage that allows a tailored approach for individual dosing variability, it also serves as some of the best evidence yet that we can manage our patients with a high-intensity strategy and avoid the costs and burdens of repeated LDL testing.
Plan de l'etude:
Randomized controlled trial (single-blinded)
There is minimal evidence supporting the superiority or noninferiority of a high-intensity strategy of statin dosing versus a strategy of treating to a target low-density lipoprotein (LDL) level. These investigators identified 4400 adults with coronary artery disease (CAD), including both stable ischemic heart disease and acute coronary syndrome. Eligible patients randomly received (concealed allocation assignment) a statin using either a strategy of treat-to-target an LDL level between 50 mg/dL and 70 mg/dL, or a strategy of high-intensity therapy (20 mg rosuvastatin or 40 mg atorvastatin daily) without dose adjustment based on follow-up LDL levels. An independent committee masked to treatment group assignment assessed outcomes. Complete follow-up occurred for 98.7% of participants at 3 years.
Using both intention-to-treat and per-protocol analysis, the primary endpoint (a composite of all-cause death, myocardial infarction, stroke, and any coronary revascularization) occurred in 8.1% of the treat-to-target group and 8.7% in the high-intensity statin therapy group (nonsignificant difference; meeting the significance for noninferiority). No significant group differences occurred for multiple prespecified secondary end points, including new-onset diabetes, elevated liver enzymes, hospitalizations, end-stage kidney disease, or study drug discontinuation due to intolerance.
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Professor of Family Medicine, UNC Chapel Hill