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Am Fam Physician. 2000;61(10):3118

Over the past few years, the management of cardiovascular disease has changed with the addition of the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, more commonly known as statins. These agents have been used for primary and secondary prevention of coronary artery disease. Vaughan and associates reviewed the various effects of statins and current recommendations for using these medications.

The basic mechanism of action of statins is the reduction of low-density lipoprotein (LDL) cholesterol levels. Statins also cause minor reductions of triglyceride levels and minor increases in high-density lipoprotein (HDL) cholesterol levels. Dyspepsia, abdominal pain and flatulence, the most common side effects, are usually mild, transient and reversible. The most important adverse effects of statins are elevations of the serum transaminase levels and development of myositis. These adverse effects are more common when statins are used in combination with other medications that inhibit the cytochrome P450 system, such as azole antifungal agents, cimetadine and methotrexate. The risk for statin-related myositis increases in patients taking gemfibrozil, nicotinic acid or macrolides.

Statins have been shown to decrease morbidity and mortality rates related to coronary artery disease. This reduction can occur through primary prevention and by treating hypercholesterolemia before the development of coronary artery disease. Secondary prevention, treating after the development of coronary artery disease, has also been shown to reduce morbidity and mortality rates.

The National Cholesterol Education Program (NCEP) has developed standards for LDL cholesterol levels. Persons who have minimal risk factors for coronary artery disease should maintain LDL cholesterol levels of less than 160 mg per dL (4.15 mmol per L). In patients with a high burden of risk factors, the recommended level is less than 130 mg per dL (3.35 mmol per L). In patients with coronary artery disease or other artherosclerotic vascular disease, the NCEP goal for LDL cholesterol level is 100 mg per dL or less (2.60 mmol per L).

The authors conclude that statin therapy has been shown to have a significant benefit in patients with artherosclerosis and in patients with coronary artery disease. The positive impact of statin therapy has been shown to occur in as little as one month after initiating therapy.

editor's note: Statins have evolved over the past few years into an integral component of primary and secondary prevention of coronary artery disease. Recent studies have suggested that they serve to lower LDL cholesterol levels and have other properties that reduce the morbidity and mortality related to this disease. Unfortunately, some recent studies suggest that physicians are not meeting the NCEP goals for LDL levels in their patients. In accordance with recent information, physicians should target LDL levels in their patients in a similar manner in which they target blood sugar levels in patients with diabetes and blood pressure levels in patients with hypertension.—k.e.m.

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