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Hypolipidemic Drugs in Coronary Artery Disease
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
Pasternak and colleagues [1] address the important question of the need for combination therapy in patients with coronary heart disease and “normal” cholesterol values. However, they imply in their introduction and discussion that the amount of low-density lipoprotein (LDL) cholesterol lowering achieved is similar for all currently approved 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). Specifically, the authors ignore the well-known dose-response curves of these agents, as shown in two studies they cite in their article. The EXCEL (Expanded Clinical Evaluation of Lovastatin) study [2] clearly shows that lovastatin has an increasing effect as doses are increased from 20 mg daily (mean LDL cholesterol lowering, 24%) to 80 mg daily (mean LDL cholesterol lowering, 40%). Similarly, Stein and colleagues [3] showed mean LDL cholesterol lowering of 32% with a simvastatin dosage of 20 mg/d and of 40% with a dosage of 40 mg/d. (Pasternak and colleagues incorrectly give the results for cholestyramine alone as the results for resin plus simvastatin therapy.) The authors would probably have seen less need for combination therapy if they had used another statin at a dosage that would have achieved more LDL cholesterol lowering.
Of more significance is the unanswered question of whether combination therapy with agents that have complementary roles (such as statins, which primarily affect LDL cholesterol levels, and niacin, which primarily affects very low density lipoprotein and high-density lipoprotein cholesterol [HDL] levels) has any advantage for clinical end points over monotherapy, which primarily targets LDL cholesterol concentrations (as mandated by the National Cholesterol Education Program [4]). The Scandinavian Simvastatin Survival Study (4S) [5] seems to indicate that, at least in patients with moderate hypercholesterolemia, marked LDL cholesterol reduction (mean decrease of 35% over 5.4 years) accompanied by a modest increase in HDL cholesterol levels and decrease in triglyceride levels has significant benefits with regard to coronary events, coronary mortality, and all-cause mortality. It is possible that patients whose LDL cholesterol level is less severely elevated may require different lipid intervention strategies to achieve a similar outcome.
William L. Isley, MD
University of Missouri-Kansas City; Kansas City, MO
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
