Auch bei niedrigem LDL-Cholesterin aggressiv therapieren - Aktueller Stellenwert der Statintherapie beim akuten Koronarsyndrom

Zusammenfassung

Für Personen mit hohem Risiko und Patienten mit „stabiler” koronarer Herzkrankheit ist die Absenkung des LDL-Cholesterins mit Statinen eine empirisch abgesicherte Strategie, um die Inzidenzrate kardiovaskulärer Ereignisse und Todesfälle zu reduzieren. Nachdem es bereits Hinweise gibt, dass eine aggressive Senkung des LDL-Cholesterins die Funktion des Gefäßsystems sehr schnell verbessern könnte, wurde jüngst auch der Einsatz von Statinen bei Patienten mit akutem Koronarsyndrom evaluiert. In der MIRACL[1]-Studie reduzierte die Behandlung mit 80 mg Atorvastatin täglich die Inzidenzrate vaskulärer Ereignisse im Vergleich zu Plazebo bei Patienten mit akutem Koronarsyndrom. Einen erstmaligen direkten Vergleich der Wirkung zweier Statine lieferte PROVE-IT[2]. Dabei war eine intensive Absenkung des LDL-Cholesterinspiegels mit 80 mg Atorvastatin einer moderaten LDL-Reduktion mit 40 mg Pravastatin signifikant überlegen. Entgegen den Erwartungen konnte jedoch eine frühe intensive Therapie mit Simvastatin im Vergleich zu einer verzögert einsetzenden, weniger intensiven Therapie (Studie „A to Z”[3]) keinen statistisch signifikanten Unterschied zwischen den beiden Behandlungsgruppen dokumentieren. Gerade aufgrund des hohen absoluten Risikos der Patienten mit akutem Koronarsyndrom ist dennoch eine aggressive Senkung des LDL-Cholesterins auch noch bei niedrigeren Werten vor der Behandlung gerechtfertigt. Die Wahl der Substanz sollte sich an der Studienlage orientieren.

Zusammenfassung

Lowering LDL cholesterol with statins is an empirically supported strategy to reduce the incidence rate of cardiovascular events and deaths in individuals at high cardiovascular risk and in patients with stable coronary artery disease. As aggressive lowering of LDL may have immediate effects on the function of the vascular system, the use of statins has recently been evaluated in patients with acute coronary syndromes. In the MIRACL study, treatment with 80 mg atorvastatin daily reduced the incidence rate of vascular events compared to placebo in patients with acute coronary syndrome. The PROVE-IT study was the first trial to compare the effects of two statins directly: In this study, an intensive LDL-cholesterol lowering therapy with Atorvastatin (80 mg per day) could outplay a moderate LDL-lowering strategy (40 mg Pravastatin per day) significantly. In the A to Z study early intensive therapy with simvastatin was compared to a delayed less intensive therapy. Unexpectedly, there was no statistically significant difference between the two treatment groups. Given the high absolute risk of the patients with acute coronary syndrome, aggressive LDL lowering is justified in these patients. The choice of the statin should be guided by the evidence available from clinical trials.

LDL cholesterol - statins - cardiovascular events - cardio-vascular risk - coronary artery disease

Literatur

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1 myocardial ischemia reduction with aggressive cholesterol lowering

2 pravastatin or atorvastatin evaluation and infection therapy

3 aggrastat to zocor

4 global use of strategies to open occluded coronary arteries

5 platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy

6 fluvastatin on risk diminishing after acute myocardial infarction

7 heart protection study

8 cholesterol and recurrent events

9 scandinavian simvastatin survival study

Anschrift des Verfassers