West of Scotland Coronary Prevention Study

Long-Term Follow-Up of a Landmark Statin Trial
The benefits of statin therapy lasted 10 years.


The West of Scotland Coronary Prevention Study was the first large randomized trial of statin therapy in people without a history of coronary events (Journal Watch Nov 28 1995). Pravastatin, compared with placebo, was associated with a significantly lower 5-year rate of death from coronary heart disease or nonfatal myocardial infarction (5.5% vs. 7.9%) and a statistically borderline reduction in all-cause mortality (3% vs. 4%). Now, researchers present an additional 10 years of follow-up data. About one third of patients in both groups were taking statins 5 years after the trial ended; no data were available for statin therapy beyond that time point.

At 15 years, the following outcomes were noted in the original pravastatin group compared with the original placebo group:


Significantly lower rate of death from CHD or nonfatal MI (12% vs. 16%)

Significantly lower CHD mortality (5% vs. 6%)

Significantly lower all-cause mortality (19% vs. 21%)

No significant difference in rates of fatal or nonfatal stroke

No significant difference in cancer rates


Comment: This partly industry-supported extended follow-up of a landmark primary prevention trial shows that the benefits of statin therapy were durable, even though only a minority of patients in both groups took statins after conclusion of the trial. The authors attribute their findings to stabilization of existing plaque and slowing of progression of coronary artery disease. Keep in mind that this study population was high-risk to begin with — participants were middle-aged men with a mean LDL cholesterol of 192 mg/dL, and most were current or ex-smokers.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 11, 2007

Citation(s):

Ford I et al. Long-term follow-up of the West of Scotland Coronary Prevention Study. N Engl J Med 2007 Oct 11; 357:1477.

HDL Levels Remain Predictive of Heart Risk Even in the Face of Very Low LDL

HDL levels retain their prognostic value in patients treated with statins — even among those who achieve very low LDL levels — researchers report in the New England Journal of Medicine.


A post hoc analysis from the industry-funded Treating to New Targets study examined the predictive value of HDL levels on nearly 10,000 adults with coronary heart disease after 3 months of atorvastatin treatment.


After multivariate adjustment, the 5-year risk for major cardiovascular events was reduced by 25% among patients in the highest quintile of HDL cholesterol compared with those in the lowest quintile. Even among patients who had achieved LDL levels below 70 mg/dL, risk remained significantly reduced (by 39%) in the highest HDL quintile.


Writing in Journal Watch General Medicine, Allan S. Brett concludes: "Whether patients with both low LDL and low HDL would benefit from additional drug therapies to raise HDL cholesterol is unclear. "

Nonfasting Trigylceride Levels Seem Better at Defining Risk for Heart Disease

Two studies measuring triglycerides in the nonfasting state show a strong association between elevated levels and risk for cardiovascular disease or death. Both appear in today's JAMA.

One study, using a population sample from Copenhagen, followed nearly 14,000 men and women for an average of 26 years. Researchers found that the risk for MI, ischemic heart disease, or death increased with increasing levels of nonfasting triglycerides, especially among women.

Another study, performed within the Women's Health Initiative, followed some 26,500 women for a median of 11 years and compared the effects of fasting versus nonfasting triglycerides on risk for cardiovascular events. When measured in the nonfasting state (especially 2 to 4 hours postprandially), triglyceride levels showed a strong, independent association with future risk, which persisted in fully adjusted analyses. Fasting levels, according to the authors, "showed little independent association with cardiovascular events."

According to an editorialist, the results "suggest that using 2- to 4-hour postprandial triglyceride measurements may be more predictive [of risk] than LDL-C."