Overuse alert: treat-to-target LDL strategy of statin dosing is noninferior to high-intensity dosing

Clinical Question

Is a strategy of treat-to-target statin dosing noninferior to high-intensity dosing for adults with coronary artery disease?

Bottom line

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. 1b

Study design: Randomized controlled trial (single-blinded)

Funding: Industry

Setting: Outpatient (any)

Reviewer

David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC


Discuss this POEM


Comments

ARUP KUMAR DHARA

Impact assessment

Excellent

Anonymous

Info Poems

Please keep info poems CMA! It's your best feature :)

Anonymous

LDL target

Cardiologists routinely target LDL levels, so unless this changes, no change will occur at the primary care level.

Anonymous

What is considered high dose statin?

I would consider crestor 40mg and lipitor 80mg as high dose statins. I wonder if the results would be different if they used those does in the comparator arm.

Howard David Koseff

Whack EM with max dose?

Why not? Then no LDL testing. What a biased commentary

Judy Patterson

I have a different take…

Their conclusion is such that it is ‘non-inferior’ to use high dose, but my conclusion is that it is non-inferior to not be as aggressive.

Anonymous

cost

I think the long term costs of high intensity treatment are likely higher than testing til get to target and then stop testing.

Anonymous

SI Units

It would useful to have the SI units in brackets after the numbers quoted.

Anonymous

Treat to Target LDL strategy

The evidence based medicine group at University of Alberta and the Tools for Practice of the Alberta College of Family Physicians have long shown that LDL (indeed all lipids) are surrogate markers. Once someone is on a statin there is no need to monitor lipid levels. The use of using cholesterol targets for reducing CVD is not required. See the Clinical Practice Guideline as published in the Canadian Family Physician.

Raymond Gaston Jacques

dosing

It is misleading to say that this study used "high dose " statin when it did not. High dose is crestor 40 or lipitor 80mg as a previous colleague indicated and I would add, that ezetrol, vascepa, and even Repatha can be added to make it truly High dose lipid management.
Further, the Repatha studies have presented the concept of lowering Lipoprotein A with Repatha, something that is not as possible with the statins. When you consider the overall health implications of CVS disease in our population, I feel that we still need to do more.

Anonymous

lipid treatment

target ok