From the Guidelines
Statins decrease cardiovascular mortality by approximately 31% in high-risk patients, as evidenced by the most recent and highest quality study. This reduction varies based on the specific statin, dosage, patient risk factors, and duration of treatment. According to the study by Chou et al. 1, in adults at increased cardiovascular disease (CVD) risk, statin therapy is associated with reduced risk of all-cause mortality and cardiovascular mortality. The study found that statin therapy reduced the risk of cardiovascular mortality by 31% (risk ratio 0·69,95% CI 0·54,0·88).
The mortality benefit of statins generally increases with longer duration of therapy, with effects becoming significant after about 1-2 years of consistent use. Statins work primarily by inhibiting HMG-CoA reductase, which reduces cholesterol synthesis in the liver, leading to lower LDL cholesterol levels. Beyond cholesterol reduction, statins also have pleiotropic effects including improved endothelial function, reduced inflammation, and stabilization of atherosclerotic plaques. These mechanisms collectively contribute to the reduction in cardiovascular events and mortality.
Some key points to consider when prescribing statins include:
- The greatest benefit is seen in patients with established cardiovascular disease, diabetes, or multiple risk factors.
- Common statins include atorvastatin (10-80mg daily), rosuvastatin (5-40mg daily), simvastatin (10-40mg daily), and pravastatin (10-80mg daily).
- Side effects like muscle pain, liver enzyme elevations, and slightly increased diabetes risk should be monitored, but for most high-risk patients, the cardiovascular mortality benefits substantially outweigh potential risks. The USPSTF also found that use of low- to moderate-dose statins reduces the probability of CVD events and mortality by at least a small amount in adults aged 40 to 75 years who have 1 or more CVD risk factors 1. However, the study by Chou et al. 1 provides more specific and detailed information on the reduction in cardiovascular mortality associated with statin therapy.
From the FDA Drug Label
In the LIPID study, the effect of pravastatin, 40 mg daily, was assessed in 9,014 patients... Table 7: LIPID - Primary and Secondary Endpoints ... CHD mortality 287 (6.4) 373 (8.3) 24% 0.0004 In the CARE study, the effect of pravastatin, 40 mg daily, on CHD death and nonfatal MI was assessed in 4,159 patients ... Cardiovascular deaths were decreased by 32% (73 vs 50) In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium on fatal and non-fatal coronary heart disease was assessed in 10,305 patients ... Atorvastatin calcium significantly reduced the rate of coronary events ... with a relative risk reduction of 36% In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of atorvastatin calcium on cardiovascular disease (CVD) endpoints was assessed in 2,838 subjects ... Atorvastatin calcium significantly reduced the rate of major cardiovascular events ... with a relative risk reduction of 37%
Statins decrease CV mortality by:
- 24% in the LIPID study with pravastatin 40 mg daily 2
- 32% in the CARE study with pravastatin 40 mg daily 2
- 36% in the ASCOT trial with atorvastatin calcium 10 mg daily 3
- 37% in the CARDS trial with atorvastatin calcium 10 mg daily 3
From the Research
Statin Therapy and Cardiovascular Mortality
- Statins are associated with a decreased risk of cardiovascular mortality, with a risk ratio (RR) of 0.69 [95% CI, 0.54 to 0.88] 4.
- The absolute risk difference (ARD) for cardiovascular mortality is -0.43% [95% CI, -0.75% to -0.11%] 4.
- Statin therapy is responsible for about half of the decrease in cardiovascular mortality over the past several decades 5.
- The benefit of statins in patients with coronary heart disease and diabetes is twice as much as compared to the risk in patients with coronary heart disease but no diabetes 5.
Reduction in Cardiovascular Mortality
- Statins reduce the risk of all-cause mortality by 11-14% [RR, 0.86 [95% CI, 0.80 to 0.93]; ARD, -0.40% [95% CI, -0.64% to -0.17%]] 4.
- The reduction in cardiovascular mortality is greater in patients at higher baseline risk 4.
- Statins decrease the risk of cardiovascular events, including myocardial infarction, stroke, and unstable angina 4, 6.
Comparison of Statin Types
- Atorvastatin and rosuvastatin are the most effective statins in reducing cardiovascular events 6.
- Atorvastatin appears to have the best safety profile among statins 6.
- The benefit-harm profile differs by statin type, and a quantitative assessment of the benefit-harm balance is needed to inform whether statins provide net benefit 6.