Can Statins Halt Coronary Disease?

In the March 3, 2004 issue of the Journal of the American Medical Association, results of the REVERSAL study were published. This study examined the ability of atorvastatin (Lipitor) and pravastatin (Pravachol) to halt the progression of coronary artery disease.

In this study, 654 patients with coronary artery disease were randomized to receive either high-dose atorvastatin or high-dose pravastatin. After 18 months, coronary artery plaques in those treated with atorvastatin showed no further growth. Plaques in patients receiving pravastatin continued to grow.

Further, LDL levels dropped by 46% with atorvastatin, and only by 25% with pravastatin. Additionally, CRP levels dropped more significantly with atorvastatin.

There was no difference in side effects between the two groups of patients. The study was not large enough to detect whether one group or another had fewer heart attacks, strokes, or cardiovascular deaths.

DrRich Comments:

This is one of the first head-to-head studies, comparing the effects of statin drugs, to be reported. It appears to show that atorvastatin, when used aggressively (80 mg daily,) has the potential to actually halt the progression of coronary artery disease. Pravastatin, as used in this study (40 mg daily,) did not.

So should everyone receiving pravastatin be switched to atorvastatin? Maybe it will turn out that way, but the decision at this point is not entirely clear-cut. The method used to measure the "volume" of plaque in this study is subject to some degree of measurement error, and the differences between the two groups, while statistically significant, was relatively small.

And it is not at all clear that, even if these results were validated with more studies, atorvastatin would be the statin of choice. Simvastatin, for instance, was recently shown to increase HDL levels significantly more than atorvastatin.

Finally, the biggest issue in managing cholesterol levels is not in deciding which statin to choose - this is actually the 3rd most important issue. The most important is in recognizing the cholesterol problem and deciding treating it in the first place, and the next most important is to be sufficiently aggressive in treating, whichever treatment is chosen. In the vast majority of patients with high cholesterol, one or both of these steps is overlooked, rendering moot the the issue of which statin is "best." As usual, one must address the basics before worrying too much about refinements.