Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyApril 2023
Treating to a target LDL-cholesterol level below 1.81 mmol/L was noninferior to a high-intensity statin strategy in preventing major clinical outcomes.
One guideline-recommended approach to initial statin treatment for patients at high cardiovascular risk is to use a high-intensity statin to lower LDL-cholesterol by at least 50%. The LODESTAR multicentre, open-label, randomised trial, involving patients with coronary artery disease (CAD) in South Korea, assessed the noninferiority of an alternative approach: begin with a lower-intensity statin, and titrate the dose as needed to achieve a specific LDL-cholesterol target.
In all, 4400 patients (mean age, 65 years; 28% women) were randomised to either the high-intensity statin strategy (rosuvastatin 20 mg/day or atorvastatin 40 mg/day) or the treat-to-target strategy (target LDL-cholesterol, 1.29 mmol/L to less than 1.81 mmol/L). During the three-year study, mean LDL-cholesterol was 1.77 mmol/L in the high-intensity group and 1.79 mmol/L in the treat-to-target group. Within three years, incidence of the primary composite endpoint – death, myocardial infarction, stroke or coronary revascularisation – was 8.7% in the high-intensity group and 8.1% in the treat-to-target group (p<0.001 for noninferiority; prespecified margin, 3.0 percentage points).
Comment: In this trial, a treat-to-target LDL-cholesterol strategy was noninferior to a high-intensity statin strategy in patients with CAD. The two strategies achieved similar LDL-cholesterol levels and clinical outcomes. Notably, only 60% of the treat-to-target group reached LDL-cholesterol below 1.81 mmol/L, so it is possible that additional LDL-cholesterol lowering would have enhanced the strategy’s benefit. For now, the findings suggest that either a treat-to-target or a high-intensity statin approach is reasonable for patients with CAD.
Karol E. Watson, MD, PhD, FAC
John C. Mazziotta, MD, PhD, Term Endowed Chair and Professor of Medicine/Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, USA.
Hong S-J, et al. Treat-to-target or high-intensity statin in patients with coronary artery disease: a randomized clinical trial. JAMA 2023 Mar 6; e-pub (https://doi.org/10.1001/jama.2023.2487).
This summary is taken from the following Journal Watch titles: Cardiology, Ambulatory Medicine, General Medicine