Stephen J. Nicholls, MBBS, PhD; E

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Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis Stephen J. Nicholls, MBBS, PhD; E. Murat Tuzcu, MD; Ilke Sipahi, MD; Adam W. Grasso, MD; Paul Schoenhagen, MD; Tingfei Hu, MS; Kathy Wolski, MPH; Tim Crowe, BS; Milind Y. Desai, MD; Stanley L. Hazen, MD, PhD; Samir R. Kapadia, MD; Steven E. Nissen, MD Published in JAMA February 7, 2007

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Background Statins reduce low-density lipoprotein cholesterol (LDL-C) levels and slow progression of coronary atherosclerosis. Statins have been reported to increase high-density lipoprotein cholesterol (HDL-C) levels by 5% to 15%, but it has never been established that these small statin-induced increases in HDL-C translate into a meaningful clinical benefit. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Background (cont.) This study investigated the relationship between changes in lipoprotein levels and atheroma volume in patients with coronary artery disease (CAD) who were treated with statins. The principal objective was to determine the relative contribution of statin-induced reductions in atherogenic lipoproteins and increases in HDL-C on the rate of atheroma progression. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Study Design 1455 patients from 4 trials (REVERSAL, CAMELOT, ACTIVATE, ASTEROID) with CAD undergoing serial intravascular ultrasonography while receiving statin treatment. Post-hoc analysis of raw data from the four prospective, randomized trials. Follow-up at 18 or 24 months. Exclusion criteria: Target segment selected was required to have no greater than 50% lumen narrowing for a length of at least 30 mm and target vessel required to have not previously undergone percutaneous coronary intervention. REVERSAL n=502 CAMELOT n=240 ACTIVATE n=364 ASTEROID n=349 18 or 24 mos. follow-up Primary Endpoint: Relationship between changes in LDL-C and HDL-C levels and atheroma burden. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Baseline Characteristics Characteristic REVERSAL (n=502) CAMELOT (n=240) ACTIVATE (n=364) ASTEROID (n=349) Length of study, mo 18 24 Age, mean (SD) 56.2 (9.5) 56.7 (9.9) 59.4 (9.6) 58.5 (10.0) Men 362 (72.1) 187 (77.9) 261 (71.7) 245 (70.2) White race 444 (88.4) 223 (92.9) 327 (89.8) 338 (96.8) Body mass index, mean (SD) 30.5 (6.1) 30.2 (4.9) 30.7 (5.6) 29.1 (4.9) Diabetes 95 (18.9) 39 (16.3) 94 (25.8) 46 (13.2) Hypertension 348 (69.3) 152 (63.3) 271 (74.5) 335 (96.0) Metabolic Syndrome 292 (58.2) 107 (44.6) 179 (49.2) 165 (47.3) Current Smoker 132 (26.3) 56 (23.5) 74 (20.3) NA Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Baseline Characteristics (cont.) Characteristic REVERSAL (n=502) CAMELOT (n=240) ACTIVATE (n=364) ASTEROID (n=349) Previous event or procedure MI PCI CABG surgery 181 (36.1) 357 (71.1) 15 (3.0) 81 (33.8) 71 (29.6) 9 (3.8) 114 (31.3) 297 (81.5) 20 (5.5) 107 (30.7) NA Baseline medication use Statin β-blocker ACE inhibitor Aspirin 144 (28.7) 361 (72.0) 240 (47.8) 471 (93.8) 113 (47.1) 198 (82.5) 15 (6.4) 231 (96.2) 321 (88.2) 273 (74.9) 211 (58.1) 355 (97.5) 278 (79.6) 177 (50.7) 331 (94.8) Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Laboratory Values and Atheroma Volume Laboratory Values and Atheroma Volume of Patients Stratified by Study* REVERSAL (n=502) CAMELOT (n=240) ACTIVATE (n=364) ASTEROID (n=349) Baseline Level Cholesterol, mg/dL Total LDL HDL 232.2 (34.2) 150.2 (26.9) 42.6 (10.7) 179.9 (37.8) 102.8 (31.6) 40.4 (11.8) 170.1 (35.2) 94.3 (30.3) 43.3 (10.9) 204.0 (41.2) 130.4 (34.3) 43.1 (11.1) Triglycerides, mg/dL† 175.0 (130.0 to 237.0) 141.6 (106.2 to 221.3) 144.0 (105.0 to 199.0) 135.0 (97.0 to 187.0) CRP, mg/dL† 2.9 (1.4 to 6.1) NA 2.7 (1.1 to 5.9) Percent atheroma volume 38.9 (11.0) 41.1 (9.8) 39.8 (9.1) 39.6 (8.5) Total atheroma volume, mm3 190.3 (83.5) 198.2 (80.9) 172.7 (78.1) 188.6 (72.3) *Values are expressed as mean (SD) unless otherwise indicated †Values are expressed as median (interquartile range) Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Laboratory Values and Atheroma Volume (cont.) Laboratory Values and Atheroma Volume of Patients Stratified by Study (cont.) REVERSAL (n=502) CAMELOT (n=240) ACTIVATE (n=364) ASTEROID (n=349) Change from baseline Cholesterol, mg/dL Total LDL HDL -65.2 (37.6) -58.7 (32.5) 1.9 (6.0) 0.6 (35.7) -2.6 (28.9) 1.7 (8.0) -0.4 (26.8) -0.6 (24.0) 1.2 (5.5) -63.2 (30.9) -63.9 (27.8) 5.7 (6.8) Triglycerides, mg/dL† -34.9 (-72.5 to -5.7) 6.6 (-42.0 to 46.5) -1.8 (-28.3 to 21.8) -19.3 (-49.5 to 6.7) CRP, mg/dL† -0.4 (-1.8 to 0.9) NA -0.2 (-2.0 to 0.8) Percent atheroma volume 1.3 (5.1) 0.5 (3.0) 0.5 (3.5) -0.7 (2.4) Total atheroma volume, mm3 2.5 (30.4) 0.3 (18.5) -3.8 (18.6) -9.8 (17.1) Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Level, Mean (SD) [Median]* Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Pooled Data for Atheroma Change in Biochemical Parameters and Atheroma Volume in Patients Receiving Statin Therapy Pooled Data for Change in Biochemical Parameters and Atheroma Volume in Patients Receiving Statin Therapy (n=1455) Level, Mean (SD) [Median]* At Baseline During Treatment Mean (SD) P Value Cholesterol, mg/dL (n=1455) LDL HDL 124.0 (38.3) [126.0] 42.5 (11.0) [41.0] 87.5 (28.8) [85.6] 45.1 (11.4) [43.7] -36.7 (41.1) 2.6 (6.7) <0.001 LDL/HDL ratio (n=1455) 3.0 (1.1) [3.0] 2.1 (0.9) [1.9] -1.0 (1.1) Percent atheroma volume 39.7 (9.8) [40.0] 40.1 (9.7) [40.1] 0.5 (3.9) 0.001 Total atheroma volume, mm3 186.8 (79.5) [176.2] 184.4 (78.2) [174.3] -2.4 (23.6) Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Results In univariate analysis, mean levels and treatment-mediated changes in LDL-C, total cholesterol, non-HDL-cholesterol, apolipoprotein B, and ratio of apolipoprotein B to apolipoprotein A-I were significantly correlated with the rate of atherosclerotic progression, whereas treatment-mediated changes in HDL-C were inversely correlated with atheroma progression. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Results (cont.) In multivariate analysis, mean levels of LDL-C (β coefficient, 0.11 [95% confidence interval, 0.07-0.15]) and increases in HDL-C (β coefficient, -0.26 [95% confidence interval, -0.41-0.10]) remained independent predictors of atheroma regression. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

No significant differences were found with regard to clinical events. Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Results (cont.) Substantial atheroma regression (≥5% reduction in atheroma volume) was observed in patients with levels of LDL-C less than the mean (87.5 mg/dL) during treatment and percentage increases of HDL-C greater than the mean (7.5%; P<0.001). No significant differences were found with regard to clinical events. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Limitations This study was a post-hoc analysis that incorporated the data from patients who participated in 4 different clinical trials. The individual studies differed in length of time between baseline and follow-up ultrasound evaluations and required adjustment in both univariate and multivariate analysis; it remains to be determined whether atheroma progression with time is linear. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Limitations (cont.) The findings are derived from patients with CAD diagnosed at angiography performed for a clinical indication and cannot be extrapolated to the setting of primary prevention. The requirement for an invasive catheterization procedure for a clinical indication, variable lipid inclusion criteria, and differences between studies in terms of the statin being the active treatment or background therapy may have allowed for sampling biases. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Limitations (cont.) Intravascular ultrasonography provides a suboptimal characterization of plaque components. Thus, it remains uncertain whether simultaneous lowering of LDL-C and raising of HDL-C has an incremental beneficial effect on plaque stabilization with statins. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Limitations (cont.) While the results demonstrate a favorable effect of increasing levels of HDL-C, the relationship between statin-induced changes in HDL subclasses and the rate of progression of atherosclerotic plaque remains to be investigated. Similarly, the effect of differing duration of statin use prior to enrollment and potential lifestyle changes by subjects remains uncertain. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Limitations (cont.) Smoking and revascularization data were not collected in the ASTEROID study. Given the limited evidence correlating favorable changes in plaque progression with a reduction in clinical events, it remains to be demonstrated that simultaneous lowering of LDL-C and elevation of HDL-C translates to less clinical events. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Summary Statin therapy is associated with regression of coronary atherosclerosis when LDL-C is substantially reduced and HDL-C is increased by more than 7.5%. These findings suggest that statin benefits are derived from both reductions in atherogenic lipoprotein levels and increases in HDL-C. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.

Statins, High-Density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis: Summary (cont.) However, it remains to be determined whether the atherosclerotic regression associated with these changes in lipid levels will translate to meaningful reductions in clinical events and improved clinical outcomes. Nicholls SJ, et al. JAMA. 2007 Feb; 297(5): 499-508.