Atorvastatin: gold standard for prophylaxis of myocardial ischemia and stroke - comparison of the clinical benefit of statins on the basis of randomized controlled endpoint studies.

AIM: of this study was to compare the clinical benefit - reduction of heart attacks, strokes or deaths - of the different statins applying the results of randomized controlled endpoint studies. - METHOD: We analyzed 11 published randomized controlled endpoint studies statin-to-placebo looking for the cardiovasculoprotective benefit of the 5 statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin) tested: AFCAPS/TexCAPS, ASCOT, CARE, FLORIDA, HPS, PROSPER, LIPID, LIPS, MIRACL, 4S, WOSCOPS. - RESULTS: 1. Statins produced substantial benefit for the patients, reducing the rate of cardiovascular morbidity and mortality. 2. This benefit was independent of the patient's initial cholesterol or LDL-cholesterol concentrations and could also be demonstrated in patients who had average or low cholesterol levels. 3. Men and women showed a comparable benefit from statin treatment, elderly patients a little more than younger patients. 4. The statins did not have like effects. There were clear differences in potency as well as in the interval between initiation of treatment and the onset of clinical benefit. 5. Estimating 5 years of treatment, cardiac morbidity decreased with atorvastatin up to 44 %, with pravastatin up to 36 %, with fluva- or simvastatin up to 32 % and with lovastatin up to 24 %, approximately. 6. Estimating 5 years of treatment, morbidity of suffering from stroke decreased with atorvastatin up to 41 %, with simvastatin up to 34 % and with pravastatin up to 31 %, approximately. For fluva- and lovastatin there are no comparable data. Within the first 16 weeks of treatment following an acute coronary syndrome relative risk for suffering a non-lethal stroke was reduced with atorvastatin 80 mg/day up to 59 % compared to placebo, the relative risk for stroke up to 50 %. 7. The fastest onset of clinical benefit - reduction of fatal and non-fatal cardiovascular events, hospitalization and necessity of invasive interventions - was demonstrated by treatment with atorvastatin (rapid, within some weeks), followed by lovastatin (after one year), fluva-, prava- and simvastatin (after 11/2 - 2 years). 8. These results were achieved with atorvastatin 10 mg/day (80 mg/day used in MIRACL), lovastatin 20 to 40 mg/day (caused by dosage titration), pravastatin 40 mg/day, simvastatin 20 to 80 mg/day (caused by dosage titration) or fluvastatin 80 mg/day. 9. The advantage of atorvastatin may be due to its ability to reduce cardiovascular disease by stopping the growth of plaques in artery walls. 10. Atorvastatin was the most powerful compound in the group of statins, improving patients' health and expectation of life. - CONCLUSIONS: The authors of the studies agree, that patients at risk for cardiovascular diseases should be treated with a statin irrespective of initial cholesterol concentrations, sex or age. If an acute cardiovascular event has happened, statin treatment should be initiated early to improve the prognosis of these patients at high risk, independent from initial LDL cholesterol values. - Summing-up of these 11 trials, the best results and the greatest benefit for the patients were achieved with atorvastatin, which might be considered to be the gold standard for prophylaxis of cardiac ischemia and stroke.