5MinuteConsult Journal Club

Just Give a High Intensity Statin in CAD

Reference

JAMA. Published online March 6, 2023. doi:10.1001/jama.2023.2487

Study Summary/Outcomes

This RCT of 4400 patients in South Korea with known coronary artery disease compared using a high intensity statin (high intensity group) to titrating the statin to an LDL goal of 50-70 mg/dL (treat-to-target group) on the composite outcome of all-cause death, myocardial infarction, stroke, or any coronary revascularization.

At 3 years, the mean LDL-C level was 69.1 mg/dL in the treat-to-target group and 68.4 mg/dL in the high-intensity statin group (P = .21). The primary end point occurred in 177 patients (8.1%) in the treat-to-target group and 190 patients (8.7%) in the high-intensity statin group (absolute difference, –0.6 percentage points, meeting the requirements for “non-inferiority.”)

Conclusions

Using a high intensity statin is as effective as attempting to titrate a statin to an LDL goal of 50-70 mg/dL.

Discussion

The American College of Cardiology/American Heart Association has produced a variety of guidelines with some strong evidence-based recommendations, but a significant amount of “Expert Opinion” recommendations. Getting your LDL < 70 mg/dL has never been substantiated in the literature, and this study further demonstrates that using a high intensity statin is sufficient.

Why is lower not better? No one knows, but some suggest the statins primary effect is on coronary artery plaque inflammation. The majority of a statin’s benefit likely comes from some mechanism associated (but not necessarily) with serum LDL.

For your patients with known CAD, feel confident they are receiving adequate care being on a high intensity statin, and worry less about chasing an arbitrary LDL goal.

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