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Cholesterol Management and Risk Reduction
Implications of the REALITY Asia Study A sub-optimal level of cholesterol goal attainment has been observed
Diabetes Subgroup Analysis outside Asia. The EUROASPIRE I and II studies found that 41% of the
This study has clearly demonstrated that Asian therapeutic approaches participants and 49% of those on lipid-lowering therapy attained the more
are not achieving the recommended targets for cholesterol goal conservative goal of total cholesterol <5mmol/l and LDL-C <3mmol/l
achievement. The greatest paradox in these results is that the patient (116mg/dl).
22
Among two-thirds of the diabetes subgroup taking lipid-
group with the highest risk – i.e. those with diabetes/CHD – are the most lowering drugs, 52% attained <3.0mmol/l and 32.4% achieved
under-treated group. Their rate of goal attainment was only 38% <2.5mmol/l (<97mg/dl).
23
The findings of the Europe REALITY study were
compared with 62 and 81% in the other primary prevention groups; similar: 90% of patients were initially on medium- or lower-potency statin
therefore, the first aim for Asian healthcare professionals should be to doses, despite many requiring a 50% reduction in LDL-C to attain the
improve treatment of this group. NCEP-ATP III-recommended level.
24
Cholesterol goals were achieved overall
in 41% of participants, with a significantly lower figure in the diabetes/
A striking observation was that the initial statin dose was in the low to CHD subgroups. Overall, these data confirm the need to develop and use
moderate potency range. The average LDL-C level of the sample cohort more effective and well-tolerated initial lipid-lowering therapies in order to
was 149mg/dl; therefore, a 35% reduction was needed to achieve the help Asian patients with diabetes to achieve cholesterol goals.
cholesterol goal of <100mg/dl. Data obtained from the STELLAR trial,
which compared rosuvastatin with other statins across dose ranges for Limitations of the Study
reduction of LDL-C, suggest that such a reduction cannot be achieved A study across six countries in different clinical settings can lead to some
in high-risk groups at the statin potencies used. High doses are misleading results. For example, the high rate of goal attainment in China
required, i.e. 40mg simvastatin, 20mg atorvastatin or 10mg could be attributable to lower baseline levels of LDL-C. The distinct
rosuvastatin.
18
In terms of data obtained in this study, in order for those clinical setting of the Chinese patients may also have been a factor: most
in the diabetes/CHD subgroup to achieve a target of 70mg/dl, a greater were hospitalised due to the onset of CHD, and of these patients 50%
than 50% reduction in LDL-C was needed. Even the highest dose of had undergone percutaneous coronary intervention (PCI). As a result,
simvastatin and pravastatin could not achieve this; atorvastatin falls these patients may have been more intensively treated and/or more
slightly short of this target. However, such a reduction could be compliant with the therapy. The goal attainment in Korea may have been
achieved with rosuvastatin at 20mg. low because the study period was earlier than that of other countries
(2002–2003 versus 2004 for others). When the study was repeated in
Other drugs in combination with statins have the potential to lower 2007, goal attainment significantly improved.
25
Practice patterns across
LDL-C more than statins alone. Ezetimibe (Zetia) was licensed as a treatment centres are highly variable. Furthermore, the effects of lifestyle
cholesterol-lowering drug by the US Food and Drug Administration (FDA) changes on cholesterol goal attainment were not assessed.
in 2002 and is frequently used in combination with statins, e.g. with
simvastatin as Vytorin. Vytorin at a dose of 10/20mg has the potential to Conclusion
achieve the 50% reduction of LDL-C required in this study.
19
The More than half of the participants in the REALITY Asia study did not achieve
ENHANCE study demonstrated that simvastatin and ezetimibe in the LDL-C levels recommended by NCEP-ATP III, particularly those with
combination reduced LDL-C considerably more than the statin alone; CVD/diabetes. Although goal attainment was no worse than that observed
however, this reduction was not accompanied by a reduction in intima- in European studies, the rapid growth of diabetes in this continent makes
media thickness of the carotid artery.
20
The value of uptitration of statins these findings highly significant. The high-risk status of patients with
was also analysed. Studies have shown that doubling the dose achieves diabetes should lead to a more aggressive approach in their preventative
only a 6% reduction in LDL-C.
21
Since more than 40% of patients in this care. The results have clearly demonstrated the importance of commencing
study required more than 18% reduction, even an uptitration of 3x treatment using the correct drug (either a statin or combination therapy)
would not achieve cholesterol targets. Logistic regression analysis and dose in the the shortest possible time, so as to achieve a sufficient
confirmed that uptitration was not associated with goal achievement, reduction in LDL-C to attain the required cholesterol goal target. This clearly
whereas high initial statin potency was an important factor. requires a change in mindset in the treatment of patients with diabetes.
Rather than increasing the dose, high/very high starting doses of statins or
A further important finding was the rate of improvement across the study combination therapies are required at the onset. High-potency statins such
period. A clear pattern emerged of improvement over the first three- as rosuvastatin should also be considered, as should the use of combination
month period, followed by a plateau, providing further evidence that therapies containing ezetimibe. More effective patient monitoring, more
uptitration is of limited value and that it is more effective to commence effective treatments – and adherence to these treatments – and therapeutic
treatment with a high-potency statin. lifestyle counselling may facilitate goal attainment. ■
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14 ASIA-PACIFIC CARDIOLOGY
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