This document discusses the use of statins for a 62-year-old male patient named Giuseppe Aloia who has a total cholesterol of 203 and HDL of 37. It notes his 15-20% 10-year risk of cardiovascular events according to various risk calculators. It then summarizes debates around recent changes to cholesterol treatment guidelines from the US and Europe. Specifically, it outlines criticisms of expanding statin use to those at lower risk levels and abandoning LDL cholesterol targets. It also discusses evidence that inflammatory markers like CRP may better predict cardiovascular outcomes than LDL alone. The document advocates considering multiple risk factors and markers, and maximizing evidence-based statin therapy over targeting specific cholesterol levels.

1. Statinizzati!
Elio Aloia

3. Uomo caucasico
Giuseppe Aloia
Eta 62 anni P.A 135 80 Peso 85 kg Altezza 182cm
Colesterolo totale 203 colesterolo hdl 37
Nessuna patologia degna di nota in anamnesi
FUMATORE
Madre ictus 82 anni

6. A PELLE COSA NE PENSATE…..

7. Prevenzi
one
primaria
in
soggetti
ad alto
rischio
Rischio di CVD
fatali SCORE =5%:
Target c-LDL <100
mg/dL (2,5
mmol/L)
Rischio totale di
eventi CV >7,5%:
terapia con
statine a intensità
moderata-alta.
Rischio di eventi
CV 5-7,5%: terapia
con statine a
intensità
moderata.
Differenza fra Europa ed
America !

8. Calcoliamo il rischio

10. Rischio calcolato con Ominibus
software distribuito da AHA in
ATP IV

11. Framingham Risk score
(ricordando che
statinanizzazione >20% CON
LDL>100 mg/dl....secondo ATP III
!!!!!!!)

12. Linee guida inglesi 2014!!!!
E la tabellina magica…..

14. Forse dopo le critiche
piovute alle ATPIV
 RICORDIAMO CHE LE LINEE GUIDA NICE NON SONO
DEFINITIVE, BENSì PROVVISORIE E IL PROCESSO DI
CONSULTAZIONE è APERTO FINO AL 26 MARZO.
 La stesura definitiva è prevista per Luglio

15. Ma le GUIDELINES ricalcono le
atp IV
 Si passa con la prescrizione della tastina con un rischio
del 10% a 10 anni, e non del 20% come le precedenti,
usando il QRISK (visto in precedenza)

23. Il nostro, anzi il mio Aloia
Giuseppe: 15-20% di rischio
a 10 anni di avere un ictus o
un infarto…..

24. Allora una statina a
colazione?

26. Circulation Novembre 2013
…Nejm le segnala a febbraio 2014

27. e nel corrente numero del
nejm….

29. 144 voci bibliografiche
 142. Preiss D, Seshasai SRK, Welsh P et al. Risk of
incident diabetes with intensive-dose compared with
moderate-dose statin therapy: a meta-analysis. JAMA
 141. Bonovas S, Filioussi K, Tsantes A, Sitaras NM. Use of
statins and risk of haematological malignancies: a
meta-analysis of six randomized clinical trials and
eight observational studies. British Journal of Clinical
Pharmacology 2007;64:255–62.
 139. Bukkapatnam RN, Gabler NB, Lewis WR. Statins for
primary prevention of cardiovascular mortality in
women: a systematic review and meta-analysis

30. 138. Brugts JJ, Yetgin T, Hoeks SE et al. 0
disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. Br
Med J
2009;338:b2376.
137. Ray KK, Seshasai SRK, Erqou S et al. Statins and all-cause mortality in high-risk
primary prevention: Aa
meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med
2010;170:1024–31.
136. Kizer JR, Madias C, Wilner B et al. Relation of different
measures of low-density lipoprotein cholesterol to
risk of coronary artery disease and death in a meta-regression analysis of large-scale trials of
statin therapy.
Am J Cardiol 2010;105:1289–96.
135. Messerli FH, Pinto L, Tang SSK et al. Impact of systemic hypertension on the
cardiovascular benefits of statin therapy--a meta-analysis. Am J Cardiol 2008;101:319–25.

31. 134. Cholesterol Treatment Trialists Collaboration, Kearney PM, Blackwell L et
al. Efficacy of cholesterol lowering
99. Mills EJ, Rachlis B, Wu P, Devereaux PJ, Arora P, Perri D. Primary prevention
of cardiovascular mortality
and events with statin treatments: a network meta-analysis involving more
than 65,000 patients. J Am Coll
98. Baigent C, Blackwell L, Emberson J et al. Efficacy and safety of
more intensive lowering of LDL
cholesterol: a meta-analysis of data from 170,000 participants in 26
randomised trials. Lancet
2010;376:1670–81.
83. Cholesterol Treatment Trialists C, Mihaylova B, Emberson J et al. The
effects of lowering LDL cholesterol
with statin therapy in people at low risk of vascular
disease: meta-analysis of individual data
from 27 randomized trials
.Lancet 2012;380:581-90.

32. 82. Sattar N, Preiss D, Murray HM et al. Statins and risk of
incident diabetes: a collaborative meta-
analysis of randomised statin trials. Lancet 2010;375:735–42.
50. Cholesterol Treatment Trialists Collaboration. Efficacy of cholesterol-
lowering treatment: prospective
meta-analysis of data from 90,056 patients in 14 randomized trials of
statins. Lancet 2005;366:1267–78.
13. Cholesterol Treatment Trialists Collaboration, Mihaylova B, Emberson
J et al. The effects of lowering LDL cholesterol with statin
therapy in people at low risk of vascular disease:
meta-analysis of individual data from 27 randomised trials. Lancet
2012;380:581–90.

33.  20. Cholesterol Treatment Trialists Collaboration. Efficacy and
safety of more intensive lowering of LDL
cholesterol: a meta-analysis of data from 170,000
participants in 26 randomised trials. Lancet 2010;376:1670–1681
 50. Cholesterol Treatment Trialists Collaboration. Efficacy of
cholesterol-lowering treatment: prospective meta-analysis of data
from 90,056 patients in 14 randomized trials of statins.
Lancet 2005;366:1267–78.

34. Evento cardiovascolare…. :
 Clinical ASCVD includes acute coronary syndromes,
history of MI, stable or unstable angina, coronary or
other arterial revascularization, stroke, TIA, or
peripheral arterial disease presumed to be of
atherosclerotic origin.

44. Probabilmente in prevenzione
primaria qualche domanda
dovremmo formularla…..
Attenzione all’
«ipse dixit» nei
riguardi
dell’AMERICA

45. Qualcosa non tornava
anche a me nel primo uso
del calcolatore di
rischio….figuriamoci alla
comunità scientifica

47. Sommariamente le varie critiche
che riempono i rotocalchi….ops
le riviste scientifiche
 Traslazione risultati in prevenzione primaria di studi con
coorti di pazienti in prevenzione secondaria
 Non considerare l’LDL nell’omnibus è una follia
 Abbandonare i target: questo secondo alcuni sarebbe
DAVVERO overtrattare o sottotrattare
 Seguendo….si stima 930 milioni di persone da trattare
SUL GLOBO (facciamo prima a trattare tutti i cinesi)
 Risultati degli studi VENGONO TRASLATI ARBITRARIAMENTE
IN UN IPOTETICO USO DETTATTO DA UN CALCOLATORE DI
RISCHIO SEMPLICISTICO E LARGAMENTE INCOMPLETO e
per giunta NON USATO NEGLI STUDI SU CUI SI BASA LA
LINEE GUIDA

51. Solo negli usa 8 milioni di
statinizzati in più…..
Considerando il registro NHANES
(che ha escluso pz con TG>400
mg/dl……
e confrontando gli stessi pz e
applicando i criteri di
statinizzazione di ATPIII e ATP IV,
notiamo che….(nella prox slide)

53. Con le attuali disposizione il
valore medio di LDL negli
statinizzati è di poco
superiore a 100 mg/dl

54. Volendo fare gli avvocati del
diavolo e come Parmenide
insegna…
 Da valutare anche i risultati del

55. Attenzione: che risultati
opinabili in prevenzione
primaria non screditino tuttò
però

56. Inoltre ricordiamoci che
Aloia Giuseppe secondo la
nostra European society of
Cardiology (ESC)
statinizerebbe Aloia
Giuseppe se avesse 5 anni in
più (65 anni) e mantenesse il
fumo/P.sistolica/colesterolo
attuali….ma sindacabilità
anche su scores ESC

59. Altri elementi da
considerare….
 ‡Primary LDL–C ≥160 mg/dL or other evidence of
genetic hyperlipidemias, family history of premature
ASCVD with onset <55 years of age in a first degree
male relative or <65 years of age in a first degree
female relative, high-sensitivity C-reactive
protein >2 mg/L, CAC score ≥300 Agatston units
or ≥75 percentile for age, sex, and ethnicity, ankle-
brachial index <0.9, or elevated lifetime risk of ASCVD.
 ASCVD indicates atherosclerotic cardiovascular
disease; CAC, coronary artery calcium; and LDL–C,
low-density lipoprotein cholesterol.

60. STUDIO JUPITER…RISULTATI SULLA
STELLA LINEA NELLO STUDIO
PROVE-IT
 Nello studio Jupiter, l’uso delle statine in prevenzione
primaria, riduzione hsPCR si è dimostrata un
miglior marker di predittività negativa
per eventi cardiovascolari, rispetto a
riduzione LDL, in prevenzione
primaria….miglior outcome per i pazienti con
riduzione congiunta di 2,2 mg/dl per hsPCR, e LDL<70
mg/dl
 I risultati confermavano già l’orientamento delle linee
guida canadesi del 2009 nel considerare fortemente la
valutazione della hsPCR

61. Aterosclerosi, più che malattia
di accumulo del colesterolo,
malattia infiammatoria…..
Eventi cardiovascolari correlati
ad aumento di Pcr, per rottura-
trombosi vasale

62. Inoltre….
 Invece s. longitudinali :
PCR elevata =
marcatore di rischio
ipertensione nuova
insorgenza e la
progressione accelerata
del danno
d’organo….forse oltre
quanto spiegato dal solo
aumento della PA
Inoltre studi
trasversali
mostrano forti
correlazioni tra
PCR elevata e
rigidità arteriosa
e pressione
differenziale
elevata.

63. Inoltre….
 Migliore accuratezza nel 5,7-
11,8% dei casi
La ristratificazione
considerando i valori di
hsPCR nei pazienti nel
framingham risk score,

64. Insomma….state
dormendo?

66. ( immagine di copertina della rivista: dormire
sano)

67. Il punto in generale…..
 Use of LDL–C targets may result in under-
treatment with evidence-based statin therapy or
overtreatment with nonstatin drugs that have not
been shown to reduce ASCVD events in RCTs (even
though the drug may additionally lower LDL–C and/or
non-HDL–C)


69. Il punto in prevenzione
secondaria….

70. A. Secondary prevention — Evidence supports high-intensity statin therapy for this group to
maximally lower LDL–C. It does not support the use of an LDL–C target. For example, if a
secondary prevention patient achieves an LDL–C of 78 mg/dL on a dose of 80 mg of
atorvastatin, he/she is receiving evidence-
based therapy. As of yet, there are no data to show that
adding a nonstatin drug(s) to high-intensity statin
therapy will provide incremental ASCVD risk
reduction benefit with an acceptable margin of
safety

71. LDL–C
>190 mg/dL
( una miriade di dati…)

72. In many cases, individuals with FH are unable to achieve an LDL–C
goal <100 mg/dL
For example, an individual with FH may only
achieve an LDL–C of 120 mg/dL despite use of
3 cholesterol-lowering drugs. Although this
patient may have fallen short of the 100 mg/dL
goal, they have decreased their LDL–C by
>50% (starting from an untreated LDL–C level
of ~325-400 mg/dL). These patients
are not treatment failures

73. Estimated 10-year ASCVD
risk ≥7.5%
 Data has shown that statins used for primary
prevention have substantial ASCVD risk reduction
benefits across the range of LDL–C levels of 70-189
mg/dL. Moreover, the Cochrane meta-
analysis (15), as well as a meta-analysis by
the Cholesterol Treatment Trialists (13), confirms that
primary prevention with statins reduces total mortality
as well as nonfatal ASCVD events.


74. Nel caro diabetico
 For those 40-75 years of age with risk factors, the potential
benefits of LDL–C lowering with a high-intensity statin are
substantial. Because those with diabetes often have lower LDL– C
levels than those without diabetes, "goal" directed therapy often
encourages use of a lower statin dose than is supported by the RCTs, and
nonstatin drugs may be added to address low HDL–C or high triglycerides,
for which RCT evidence of an ASCVD event reduction is lacking. Giving a
maximally-tolerated statin intensity should receive primary emphasis
because it most accurately reflects the data that statins reduce the relative
risk of ASCVD events similarly in individuals with and without diabetes, and in
primary and secondary prevention in those with diabetes, along with
evidence that high-intensity statins
reduce ASCVD events more than
moderate-intensity statins.


76. RCTs are used to identify those who are
unlikely to benefit from statin therapy despite
being at high ASCVD risk, such as those with
higher NYHA classes of heart failure or those
on hemodialysis.

78. INFATTI…..
 Effects of pitavastatin in Japanese patients with chronic heart failure: the Pitavastatin Heart Failure Study
(PEARL Study).
 Takano H, Mizuma H, Kuwabara Y, Sato Y, Shindo S, Kotooka N, Fujimatsu D, Kobayashi Y, Inoue T, Node K,
Komuro I; PEARL Study Investigators.
 Recent clinical trials using rosuvastatin, a hydrophilic statin, did not show beneficial effects on cardiovascular
events in patients with heart failure. We examined the cardioprotective effects of pitavastatin, a lipophilic
statin, on Japanese patients with chronic heart failure (CHF).
 METHODS AND RESULTS:
 A total of 574 Japanese patients with CHF were randomly assigned to the pitavastatin group (n=288) or the
control group (n=286). There was no significant difference between the 2 groups for the primary outcome,
which was a composite of cardiac death and hospitalization for worsening HF (adjusted hazard ratio (aHR):
0.922, 95% confidence interval (CI): 0.632-1.345, P=0.672). A strongly significant statistical interaction between
the effect of pitavastatin and left ventricular ejection fraction (LVEF) was found (P=0.004). In patients with
LVEF ≥30%, a significant reduction in the primary outcome (aHR: 0.525, 95% CI: 0.308-0.896, P=0.018) was
observed in the pitavastatin group. Pitavastatin did not show any effects on the primary outcome (aHR: 1.582,
95% CI: 0.890-2.813, P=0.118) in the subgroup of patients with LVEF <30%.
 CONCLUSIONS:
 Pitavastatin did not reduce cardiac death or
hospitalization for worsening HF in Japanese patients with
CHF. (UMIN-ID: UMINC000000428).

79. Infatti anche nelle ATP IV…

80. I 2 studi su cui si basa la
raccomandazione…oltre al
noto e recente studio
(CORONA) pubblicato su
CIRCULATION

81. …….E il noto studio MEGA
(Pubblicato su JAMA)….
 Insomma….credo che ci siamo convinti che iniziare la
terapia statinizzante in un gruppo determinato di
pazienti non abbia senso, in base all’evidenze
attuali….

82. Stiamo quasi per finire
 ….solo 1 minuto….

83. Qualcosa che non va c’è in
molti casi pensandoci bene…..

89. Topcat study (Dallas 2013)
Treatment of Preserved Cardiac
Function Heart Failure with an
Aldosterone Antagonist(3445 pz)
 Risultati…..riduzione, rispetto a placebo del 2%
dell’ospedalizzazioni per scomenso cardiaco, in
popolazione randomizzata a doppio cieco di pz affetti
da scompenso diastolico con l’aggiunta di
spironolattone a terapia standard (ACE, b-
bloccanti)….
 Ancora più interessanti sono i dati eco pubblicati su
Circulation (GENNAIO 2014)

90. Criteri selezione pazienti…
 TOPCAT enrolled 3445 patients at 270 sites in 6 countries,
 who met the following key inclusion criteria: (1) age ≥50 years old;
 (2) heart failure defined by the presence of ≥1 symptom at the time of
 screening and 1 sign in the previous 12 months; (3) LVEF ≥45% per
 local reading and obtained within 6 months before randomization and
 ≥6 months after myocardial infarction or other event that would affect
 LVEF; (4) controlled systolic blood pressure defined as systolic blood
 pressure <140 mm Hg or 140 to 160 mm Hg if on ≥3 antihypertensive
 medications; and (5) assignment to 1 of 2 strata within which subjects
 were randomized: either ≥1 hospitalization in the previous 12 months
 for which heart failure was a major component of hospitalization, or
 B-type natriuretic peptide (BNP) in the previous 60 days ≥100 pg/mL
 or N-terminal pro-BNP (NT-proBNP) ≥360 pg/mL. (nuove evidenze suggeriscono di
abbassare la soglia da 100 a 60 per questi pazienti…..)

94. Concludendo…..

95. Gli autori concludono
così….

97. Grazie x
l’attenzione