Lipid-lowering trials in the primary and secondary prevention of coronary heart disease: new evidence, implications and outstanding issues

Clinical, angiographic and ultrasonographic data from new trials of the primary and secondary prevention of atherosclerosis and coronary artery disease with lipid-lowering therapy are reviewed. In the West of Scotland Coronary Prevention Study pravastatin significantly decreased cardiovascular events in asymptomatic men with moderate hypercholesterolaemia without increasing noncardiovascular mortality. The favourable effects of pravastatin may also extend to carotid arteries. Preliminary data from the Cholesterol and Recurrent Events Study testify to the value of lowering cholesterol in patients with near normocholesterolaemia and established coronary artery disease. New angiographic and ultrasonographic studies concur with findings of previous trials and indicate that the benefits of statins extend to noncoronary vascular beds. Metaregression analysis of angiographic trials shows that optimal treatment for regression of coronary artery disease should aim for an LDL-cholesterol of approximately 3.0mmol/l. The value of regulating high plasma triglyceride and low HDL-cholesterol has been emphasized by a bezafibrate study. Angiographic trials also suggest that aggressive pharmacotherapy may match the beneficial effects of LDL apheresis in heterozygous familial hypercholesterolaemia. Post-hoc analyses from previous angiographic trials have provided new hypotheses for future studies. The implications of the new evidence presented is examined, as well as issues of cholesterol screening and the economics of treatment.