Several contemporary clinical trials have shown that cholesterol-lowering statin drugs reduce the risk of heart attacks in patients with coronary artery disease. This compelling body of evidence has led to the question of whether other drugs that lower cholesterol also reduce heart attacks. Older studies had certainly shown this, though these studies were from an era prior to widespread statin use. A recent study showed that in patients with a mild heart attack, adding ezetimibe — a drug that interferes with cholesterol absorption from the intestines — to a statin reduced cardiovascular risk compared with a statin alone.
Now, a carefully done meta-analysis synthesizes all the studies to date and provides some new insights. A meta-analysis is a way of combining data from many studies over several years and analyzing the data to provide a bottom-line message. This particular meta-analysis consisted of data drawn from 49 studies of a total of 312,175 patients, a staggering number. The authors included only randomized clinical trials — the most rigorous type of study — and went back all the way to 1966 in their search for relevant trials.
The degree of benefit provided by statin and certain non-statin approaches that work predominantly by increasing the number of receptors in the body to clear out LDL cholesterol was roughly similar. The non-statin approaches included diet, bile acid sequestrants, ezetimibe, and ileal bypass surgery. Additional non-statin drugs assessed included niacin and fibrates. Both types of drugs offered cardiovascular risk reduction as well, though a major caveat regarding the data supporting use of these non-statin drugs was that the trials were not done on top of statins, or did not show clear benefits when added to statins.
Another important observation in this analysis was that lower levels of achieved LDL cholesterol were associated with even lower rates of major coronary events. This held true both for secondary prevention (that is, in patients with known atherosclerosis) as well as for primary prevention (that is, in patients with elevated cholesterol and cardiovascular risk, but without apparent atherosclerosis). The data drawn from the recent studies of the potent injectable PCSK9 inhibitor drugs also seem to support the relationship of lower cholesterol levels being more beneficial. However, it should be noted that large cardiovascular outcome trials are ongoing with these expensive injectable agents, to see if in fact they do decrease heart attack rates to the extent predicted from the large reductions in cholesterol they produce.
Thus, it appears that a variety of methods to lower cholesterol — several drugs and also diet — lower cardiovascular events, such as the chances of developing a heart attack. For patients at high cardiovascular risk, in addition to a healthy diet, statins remain the first-line drug therapy. For patients who cannot tolerate statins, non-statin drugs, including some of the older drugs, may provide a reasonable degree of benefit. The answer to whether even lower degrees of cholesterol reduction achieved by PCSK9 inhibitors further decrease cardiovascular risk is eagerly awaited.
Bible verses for today’s meditation and inspiration: Matthew E. McLaren
Psalm 118:14 The LORD is my strength and song, And He has become my salvation.
Isaiah 12:1-3 Then you will say on that day, “I will give thanks to You, O LORD; For although You were angry with me, Your anger is turned away, And You comfort me. “Behold, God is my salvation, I will trust and not be afraid; For the LORD GOD is my strength and song, And He has become my salvation.” Therefore you will joyously draw water From the springs of salvation.
Jeremiah 8:15 We waited for peace, but no good came; For a time of healing, but behold, terror!
John 5:6 When Jesus saw him lying there, and knew that he had already been a long time in that condition, He said to him, “Do you wish to get well?”
1 Thessalonians 5:23 Now may the God of peace Himself sanctify you entirely; and may your spirit and soul and body be preserved complete, without blame at the coming of our Lord Jesus Christ.
1 Samuel 25:6 and thus you shall say, ‘Have a long life, peace be to you, and peace be to your house, and peace be to all that you have.
2 Samuel 20:9 Joab said to Amasa, “Is it well with you, my brother?” And Joab took Amasa by the beard with his right hand to kiss him.
Jeremiah 33:6 ‘Behold, I will bring to it health and healing, and I will heal them; and I will reveal to them an abundance of peace and truth.
Matthew 15:31 So the crowd marveled as they saw the mute speaking, the crippled restored, and the lame walking, and the blind seeing; and they glorified the God of Israel.
Acts 4:9-12 if we are on trial today for a benefit done to a sick man, as to how this man has been made well, let it be known to all of you and to all the people of Israel, that by the name of Jesus Christ the Nazarene, whom you crucified, whom God raised from the dead–by this name this man stands here before you in good health. “He is the STONE WHICH WAS REJECTED by you, THE BUILDERS, but WHICH BECAME THE CHIEF CORNER stone.
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