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Am Fam Physician. 2023;108(3):online

Clinical Question

Is a strategy of treat-to-target statin dosing noninferior to high-intensity dosing for adults with coronary artery disease (CAD)?

Bottom Line

The study found that statin dosing based on a treat-to-target low-density lipoprotein (LDL) level of 50 to 70 mg per dL (1.29 to 1.81 mmol per L) is noninferior to a high-intensity strategy to reduce adverse events in adults with established CAD. Although the authors see this as an advantage that allows a tailored approach for individual dosing variability, it also serves as some of the best evidence yet that CAD can be managed with a high-intensity strategy and patients can avoid the costs and burdens of repeated LDL testing. (Level of Evidence = 1b)

Synopsis

There is minimal evidence supporting the superiority or noninferiority of a high-intensity strategy of statin dosing vs. treating to a target LDL level. The investigators identified 4,400 adults with CAD, including stable ischemic heart disease and acute coronary syndrome. Eligible patients randomly received (concealed allocation assignment) a statin using either a strategy of a treat-to-target LDL level between 50 and 70 mg per dL or a strategy of high-intensity therapy (20 mg of rosuvastatin or 40 mg of atorvastatin daily) without a dose adjustment based on follow-up testing of LDL levels. An independent committee masked to treatment group assignment assessed outcomes. Complete follow-up occurred for 98.7% of participants at three years.

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POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see https://www.essentialevidenceplus.com/Home/Loe?show=Sort.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Natasha J. Pyzocha, DO, contributing editor.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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