CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 2, March/April 2011
102
AFRICA
Drug Trends in Cardiology
Primary prevention with statins is more cost-effective
Atherosclerosis is asymptomatic and both
patients and clinicians would prefer to
identify the condition early in order to
prevent cardiovascular events later.
Reflecting on the Canadian experi-
ence, Dr Peter Lin of the Toronto Heart
Centre noted that the Canadian health
authorities have supported the concept
of primary prevention using powerful
statins such as atorvastatin and rosuvasta-
tin. ‘Their philosophy has been to provide
benefit with statins as quickly as possible
so as to avoid the first cardiovascular
event’, he noted.
High-risk patients, according the
Canadian guidelines for the diagnosis and
treatment of dyslipidaemias, are defined
arbitrarily as a Framingham risk score
(FRS) of 20% or greater at 10 years. The
Reynolds risk score is being offered as an
alterative risk engine for women.
1
‘However, the guidelines point out
that these risk scores are short term and
if one looks at the life-time risk of men
in the lowest FRS at 50 years of age, they
are exposed to a lifetime risk of a major
cardiovascular event of one in two. For
women in this same lowest-risk category,
their lifetime risk is one in four’, Dr Lin
pointed out.
In the Canadian system, evidence of
asymptomatic atherosclerosis gained from
invasive or non-invasive testing using
coronary angiography, nuclear imaging,
stress echocardiography or ankle-brachial
index determination also puts patients
into the high-risk category for cholester-
ol-lowering treatment prior to any actual
cardiovascular events.
With regard to the role of inflam-
mation and its biomarkers, C-reactive
protein (CRP) and hs-CRP, in assessing
risk for cardiovascular events, Dr Lin
pointed out that for the majority of at-risk
patients, hs-CRP is not needed. ‘For
example, patients with cardiovascular
disease, raised LDL levels, prior myocar-
dial infarction, and with diabetes already
have a high-risk score on the FRS of more
than 20%, and a determination of hs-CRP
would not affect the clinical decision to
initiate statin therapy. Hs-CRP should
only be used to help define patients who
clinicians do not normally treat, but who
are in fact exposed to higher risk due to
their inflammatory environment adverse-
ly affecting the vasculature’, he stressed.
‘The contribution of the JUPITER
trial
2
has been to show that patients who
clinicians do not normally treat gain bene-
fit from rosuvastatin treatment, and this
benefit occurs very early, in the first six
months of treatment. There is clearly cost
saving in this early-treatment benefit with
rosuvastatin, which contrasts starkly with
the experience in the 4S study with simv-
astatin, where benefit was only derived
after a much longer period of five years’,
Dr Lin pointed out.
These differences in the speed and
depth of protection with newer agents
such as rosuvastatin argue against the
approach of using simvastatin widely.
‘In Canada there is hardly any simvasta-
tin usage, despite a very cost-conscious
environment. In fact, our regulatory envi-
ronment encourages an early primary-
prevention approach with the simple
statement: ‘If you are older than 50 years
with two risk factors, you should be
treated with an effective statin’.
J Aalbers, Special Assignments Editor
1. 2009 Canadian guidelines for the diagnosis
and treatment of dyslipidaemia and preven-
tion of cardiovascular disease in the adult.
Can J Cardiol
2009;
25
(10): 567–579.
2. Ridker PM. Rosuvastatin to prevent vascular
events in men and women with elevated CRP.
N Eng J Med
2009;
359
(21): 2195–2207.
New Dean at Stellenbosch
University
Prof Jimmy Volmink has taken office as
the seventh dean of the Faculty of Health
Sciences. He has studied widely at over-
seas universities, and has an outstanding
record and experience in teaching and
research. We wish him great success and
the courage and energy to undertake his
vision of seeing the Faculty of Health
Sciences advance and have a greater
impact in this country and internationally.
