#67 How does high dose statin compare to low dose in people with heart disease?
CLINICAL QUESTION
In patients with coronary heart disease (like previous myocardial infarction), what are the benefits and harms of prescribing high dose compared to low dose statins?
BOTTOM LINE
In patients with coronary heart disease, using high dose statins (compared to low-moderate dose) prevents one coronary heart disease (CHD) event for every 91 patients but results in one in 47 patients discontinuing therapy due to adverse events. However, low-moderate dose statin (compared to placebo) provides 2-3 times greater benefit than increasing to high dose statin. Therefore, getting and keeping patients on any statin is key, with dose adjusted up to tolerable levels.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
There at least six meta-analyses1-6 :
- Most recent: Ten trials, 41,778 patients with CHD. Mean trial duration 2.5 years.
- High dose is usually atorvastatin 80mg. Low-moderate dose varies: pravastatin 40 mg to lovastatin 5mg.
- Outcomes:
- No difference in death, cardiovascular death, or fatal myocardial infarction (MI).
- High dose reduced the combined endpoint of non-fatal MI and CHD death: 9.4% vs 10.5%, Number Needed to Treat (NNT) =91 over 2.5 years.
- Other meta-analyses have similar results. High dose statins:
- Reduced mortality in patients with acute coronary syndrome: 1,3 NNT=91 over two years.
- Increased adverse events leading to stopping therapy: Number Needed to Harm (NNH) =47.
- In patients with CHD, low-moderate dose statin (like 40mg pravastatin or 20-40mg simvastatin) compared to placebo:7
- Reduced CHD: NNT=27.
- Reduced mortality: NNT=56.
- Benefits of low-moderate dose over placebo (relative benefit 25% for CHD7 ) are larger than the benefits of high dose over low-moderate dose (only 10% incremental benefit1 ).
- Adherence to statin therapy in the community is poor (worse than trials):
- Up to 50% discontinue statin by 3 years with adverse events often cited as a reason for stopping.8-10
- Post-marketing data11,12 indicates muscle-related side effects and transaminase abnormalities increase four-five fold when increasing atorvastatin from 40 mg to 80 mg.
Latest Tools for Practice
#379 Bumpin’ Up the Protection? RSV Vaccine in Pregnancy
How effective and safe is the respiratory syncytial virus (RSV) vaccine (AbrysvoTM) when given during pregnancy?
#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?
What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?
#377 How to slow the flow IV: Combined oral contraceptives
In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
