Dear Editor;
The results of the recently published study by Cannon and colleagues [1] and the previously published Effect of Intensive Compared With Moderate Lipid-Lowering Therapy on Progression of Coronary Atherosclerosis (REVERSAL) [2] provide strong evidence that intensive statin therapy produces superior protection for patients with coronary heart disease and those who have recently had an acute coronary syndrome than does a standard regimen.
Despite previous recommendations which considered an LDL-C level of less than 100 mg per deciliter optimal, [3,4] what is emerging is that the level of reduction is what influences clinical outcomes irrespective of plasma lipid levels. This premise is supported by the findings of The Heart Protection Study,[5] in which the authors concluded that adding a statin regimen to high-risk patients provides substantial benefits irrespective of baseline cholesterol levels. Other effects of statins, such as reductions in the levels of C-reactive protein (CRP) may potentially be viewed as clinical markers for the beneficial effects of statins. However, additional studies are needed to establish the effects of statins on biologic inflammatory markers.
In light of forgoing uncertainties, what is an optimal LDLC level? I would attempt to maintain high-risk patients on intensive lipid-lowering regimen to achieve an LDL-C level below the current recommendations (~70 mg/dl), providing that such level could be achieved safely.
REFERENCES:
1. Cannon CP, Braunwald E, McCabe CH et al: Comparison of Intensive and Moderate Lipid Lowering with Statins after Acute Coronary Syndromes. N Engl J Med, 2004; 350(15): 1495–504
2. Nissen SE, Tuzcu EM, Schoenhagen P et al: JAMA; 291(9): 1071–80
3. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel
on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA, 2001; 285(19): 2486–97
4. De Backer G, Ambrosioni E, Borch-Johnsen K et al: European guidelines on cardiovascular disease and prevention in clinical practice. Atherosclerosis, 2003; 171: 145–55
5. The Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet, 2002; 360: 7–22

Keywords: Cholesterol, HDL - blood, Hydroxymethylglutaryl-CoA Reductase Inhibitors - administration & dosage, Hyperlipidemias - blood, Hyperlipidemias - drug therapy, Cholesterol, HDL - blood, Hydroxymethylglutaryl-CoA Reductase Inhibitors - administration & dosage, Hyperlipidemias - drug therapy