By: Thomas Pickering, MD, DPhil, FRCP, Director of Integrative and Behavioral Cardiology Program
of the Cardiovascular Institute at Mount Sinai School of Medicine, New York.

Several studies have shown that lowering elevated levels of blood cholesterol can prevent both first and recurrent heart attacks. The most dramatic results have been obtained with the 'statin' drugs (lovastatin, simvastatin and pravastatin), but up to now, it has not been known whether there is any benefit from lowering cholesterol that is within the normal range to begin with. The CARE (Cholesterol and Recurrent Events) study sought to answer this question by selecting people who had already had one heart attack (and hence, were at increased risk of having another), but whose cholesterols were relatively normal (a total cholesterol of less than 240 mg/dl, which in the European way of expressing cholesterol values is 6.2 mmol/l). The LDL cholesterols were between 115 and 175 mg/dl (3 to 4.5 mmol/l).

Four thousand, one hundred and fifty-nine patients who had recovered from heart attack were randomly allocated to take either pravastatin (in a dose of 40 mg per day) or placebo (inert pills) for a period of five years. About 40 percent of them also had high blood pressure. At the end of this time, the patients taking pravastatin had lower LDL cholesterols (by 32 percent), lower total cholesterols (by 20 percent), higher HDL cholesterols (by 5 percent) and lower triglycerides (by 14 percent) than the placebo group. They also showed a 24 percent reduction in the number of heart attacks and a 31 percent reduction of strokes. The benefits of pravastatin treatment were seen in patients whose LDL cholesterol was above 125 mg/dl (3.2 mmol/l) to begin with, but not if it was less than 125. Side effects of the treatment were very few. The study was sponsored by Bristol-Myers Squibb.

Doctor’s comments

The good news about the benefits of taking statin drugs keeps on coming. The message from the CARE study is that if you have already had one heart attack and have an LDL above 125 mg/dl, it is worth taking pravastatin to prevent a second heart attack. Side effects are relatively rare, and the main disadvantage is the cost. While the strict interpretation of these results is that they apply only to pravastatin, the general consensus is that there is no marked difference between the different statin drugs currently available.

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