The gap between theory and practice: what do the trials tell us?

Numerous intervention trials with statins conducted over the last two decades have demonstrated marked and significant reductions in cardiovascular event rates. Indeed, a meta-analysis of 14 such trials has demonstrated a reduction in the risk of major cardiovascular events of 21% for every decrease in LDL-cholesterol of 1 mmol/L (39 mg/dL). Recent evaluations of intensive vs. moderate lipid-lowering strategies support a 'lower is better' approach to controlling LDL-cholesterol, with some additional outcome benefits observed when LDL-cholesterol is reduced to well below the 2.6 mmol/L (100 mg/dL) guideline goal value for patients with coronary heart disease or equivalent. Accordingly, statins now provide the mainstay of pharmacological intervention for dyslipidaemia. However, a substantial burden of cardiovascular disease remains in statin-treated patients. Practical strategies are available for improving the prognosis of patients with dyslipidaemia. First, many patients with dyslipidaemia are under-treated, and it is important to adhere to evidence-based guideline targets as closely as possible to. maximize the benefits of treatment. In addition, statins do relatively little to correct low HDL-cholesterol, which is common among patients receiving lipid-modifying treatment. Correction of this independent cardiovascular risk factor, for example, with a combination of a statin plus nicotinic acid, provides an alternative evidence-based strategy for reducing the risk of an adverse cardiovascular outcome in these patients.