Evolution of the HMG CoA reductase inhibitors (statins) in cardiovascular medicine

Recent trials have broadened the evidence base for statin use. It has now been documented that these drugs are effective agents not only in the general at-risk population, but also in the primary and secondary prevention of coronary heart disease in type 2 diabetics and in the elderly. The Heart Protection Study demonstrated the benefits of statin therapy in diabetics free of vascular disease, regardless of initial low-density lipoprotein (LDL) cholesterol level. Age is no longer a barrier to treatment, as revealed in the Prospective Study of Pravastatin in the Elderly at Risk, a trial which found that even a relatively brief period of statin therapy in elderly patients can result in a 19% reduction in the risk of a coronary event.
Statins have the ability to lower the plasma concentration of all apoB-containing lipoproteins. This may help explain their clinical efficacy in diabetics who generally have unremarkable LDL-cholesterol levels. Most currently available statins are also able to induce a modest (5% to 10%) rise in high-density lipoprotein cholesterol, an effect that appears distinct from LDL lowering. This broadens their use to subjects with a variety of problems such as the metabolic syndrome and insulin resistance.
The success of large-scale trials in coronary heart disease contrasts with the abundant evidence of under-treatment, even in high-risk groups. Thus the greatest need, at present, is to close the gap between the principles and practice of coronary disease prevention.