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How many claudicants should be prescribed statins?
Eur J Vasc Endovasc Surg 25, 367±368 (2003) doi:10.1053/ejvs.2002.1813, available online at http://www.sciencedirect.com on
SHORT REPORT
How Many Claudicants Should be Prescribed Statins? E. M. Harrison and R. J. Holdsworth Department of Vascular Surgery, Stirling Royal Infirmary, Scotland, U.K.
Introduction
Results
Hyperlipidaemia is an established reversible risk factor for coronary heart disease.1,2 However, there is little positive or negative evidence for benefits of lipid lowering therapy in peripheral vascular disease,3 and no specific trials looking at HMG-CoA reductase inhibitors (statins), in these people. Peripheral vascular disease and coronary heart disease have a clear association,4 and current recommendations5±7 for lipid lowering in coronary artery disease suggest treating all people with demonstrable vascular disease and a total cholesterol 5 mmol/l. Therefore, at present the best we can infer for the management of arterial disease is based on information for cardiac disease. We have examined a population of patients presenting with suspected lower limb arterial disease and assessed their need for statin therapy by assessing their cardiac risk factors.
Of the 697 new referrals, 485 (70%) patients had lower limb arterial disease ± of whom 297 had lower limb arterial disease only ± and a further 188 (27%) also had cardiac or cerebrovascular disease (Table 1). Of the 697 new referrals 163 patients (23%) were on a statin at presentation but less than half (72; 44%) were being treated adequately. Of those patients with lower limb disease 70 (14%) had a cholesterol 55 mmol/l and were not already on a statin. Similarly, of patients with cardiac disease 31 (12%) had a cholesterol 55.0 mmol/l and were not on a statin. Only 44 of 252 (17%) patients with PVD only who should have been on a statin, were receiving lipid lowering medication. For comparison, 107 of 223 (46%) of those with cardiac disease were receiving lipid lowering medication.
Methods A lipid profile and cardiovascular history were recorded on all new referrals to a vascular clinic with symptoms suggestive of intermittent claudication during the period February 1999±June 2002. The presence of lower limb arterial disease was assessed by ankle-brachial pressure index, exercise testing, duplex ultrasound and, if appropriate, arteriography. A total cholesterol 5 mmol/l was used as the threshold for treatment. Please address all correspondence to: R. J. Holdsworth, Consultant Vascular Surgeon, Stirling Royal Infirmary, Livilands, Stirling, FK8 2AU, U.K.
Table 1. Absolute numbers of the whole patient cohort with lower limb arterial disease and numbers on a statin. The table has been divided into those with a cholesterol less than and greater or equal to 5 mmol/l.
All patients
Whole group
Cholesterol 5 mmol/l
Total
Total On Total On statin statin
On statin
Cholesterol 5 mmol/l
697
163
187
72
510
91
Patients with PVD 485 PVD alone 297 PVD CHD/stroke 188
123 44 79
125 57 68
55 12 43
360 240 120
68 32 36
Patients without PVD 212 CHD/stroke 66
40 28
62 18
17 12
150 48
23 16
PVD peripheral vascular disease, CHD coronary heart disease.
1078±5884/03/040367 02 $35.00/0 # 2003 Elsevier Science Ltd. All rights reserved.
E. M. Harrison and R. J. Holdsworth
368
Comment Eighty-four per cent of new patients with intermittent claudication have an indication for lipid lowering according to current criteria. Of those on a statin, many were inadequately treated, suggesting subtherapeutic dosing. The relatively low prescribing rate of statins in our new referrals with claudication reflects a general lack of awareness of this important aspect of vascular management in the wider medical community. The vascular outpatient clinic is an ideal place for the identification of patients with hypercholesterolaemia. Potentially, the vascular clinic is also has an important contribution to make in monitoring therapy and in the primary and secondary prevention of coronary heart disease. A cardiovascular risk evaluation and serum lipid measurement should be a compulsory part of any outpatient vascular assessment. The vast majority of patients with intermittent claudication already have an indication for lipid lowering therapy irrespective of any effect this may have specifically on their peripheral arterial disease. It is therefore unlikely that any placebo-controlled study trial could ever take place to specifically assess the effects of lipid lowering in peripheral vascular disease. The answer to the question ``should all claudicants be on a statin?'' is probably ``yes''. Rather than asking ``if''
Eur J Vasc Endovasc Surg Vol 25, April 2003
claudicants require statin therapy we should be probably be concentrating on the issue of ``how low'' we should get the cholesterol for maximum benefit.
References 1 Shepherd J, Cobbe SM, Ford I et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia. N Engl J Med 1995; 333: 1301±1307. 2 Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994; 344: 1383±1389. 3 Leng GC, Price JF, Jepson RG. Lipid-lowering for lower limb atherosclerosis (Cochrane Review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software. 4 Leng GC, Fowkes FGR. The epidemiology of peripheral arterial disease. Vasc Med Rev 1993; 4: 5±18. 5 Winyard G. Standing Medical Advisory Committee Statement on the Use of Statins. London: Department of Health, 1997. (EL(97)41HCD750IP, Aug 1997.) 6 Scottish Intercollegiate Guidelines Network. Lipids and primary prevention of coronary heart disease. In: Edinburgh: Royal College of Physicians, 1999. (SIGN publication No 40.) 7 Downs JR, Clearfield M, Weis S et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. JAMA 1998; 79: 1615±1622. Accepted
SHORT REPORT
How Many Claudicants Should be Prescribed Statins? E. M. Harrison and R. J. Holdsworth Department of Vascular Surgery, Stirling Royal Infirmary, Scotland, U.K.
Introduction
Results
Hyperlipidaemia is an established reversible risk factor for coronary heart disease.1,2 However, there is little positive or negative evidence for benefits of lipid lowering therapy in peripheral vascular disease,3 and no specific trials looking at HMG-CoA reductase inhibitors (statins), in these people. Peripheral vascular disease and coronary heart disease have a clear association,4 and current recommendations5±7 for lipid lowering in coronary artery disease suggest treating all people with demonstrable vascular disease and a total cholesterol 5 mmol/l. Therefore, at present the best we can infer for the management of arterial disease is based on information for cardiac disease. We have examined a population of patients presenting with suspected lower limb arterial disease and assessed their need for statin therapy by assessing their cardiac risk factors.
Of the 697 new referrals, 485 (70%) patients had lower limb arterial disease ± of whom 297 had lower limb arterial disease only ± and a further 188 (27%) also had cardiac or cerebrovascular disease (Table 1). Of the 697 new referrals 163 patients (23%) were on a statin at presentation but less than half (72; 44%) were being treated adequately. Of those patients with lower limb disease 70 (14%) had a cholesterol 55 mmol/l and were not already on a statin. Similarly, of patients with cardiac disease 31 (12%) had a cholesterol 55.0 mmol/l and were not on a statin. Only 44 of 252 (17%) patients with PVD only who should have been on a statin, were receiving lipid lowering medication. For comparison, 107 of 223 (46%) of those with cardiac disease were receiving lipid lowering medication.
Methods A lipid profile and cardiovascular history were recorded on all new referrals to a vascular clinic with symptoms suggestive of intermittent claudication during the period February 1999±June 2002. The presence of lower limb arterial disease was assessed by ankle-brachial pressure index, exercise testing, duplex ultrasound and, if appropriate, arteriography. A total cholesterol 5 mmol/l was used as the threshold for treatment. Please address all correspondence to: R. J. Holdsworth, Consultant Vascular Surgeon, Stirling Royal Infirmary, Livilands, Stirling, FK8 2AU, U.K.
Table 1. Absolute numbers of the whole patient cohort with lower limb arterial disease and numbers on a statin. The table has been divided into those with a cholesterol less than and greater or equal to 5 mmol/l.
All patients
Whole group
Cholesterol 5 mmol/l
Total
Total On Total On statin statin
On statin
Cholesterol 5 mmol/l
697
163
187
72
510
91
Patients with PVD 485 PVD alone 297 PVD CHD/stroke 188
123 44 79
125 57 68
55 12 43
360 240 120
68 32 36
Patients without PVD 212 CHD/stroke 66
40 28
62 18
17 12
150 48
23 16
PVD peripheral vascular disease, CHD coronary heart disease.
1078±5884/03/040367 02 $35.00/0 # 2003 Elsevier Science Ltd. All rights reserved.
E. M. Harrison and R. J. Holdsworth
368
Comment Eighty-four per cent of new patients with intermittent claudication have an indication for lipid lowering according to current criteria. Of those on a statin, many were inadequately treated, suggesting subtherapeutic dosing. The relatively low prescribing rate of statins in our new referrals with claudication reflects a general lack of awareness of this important aspect of vascular management in the wider medical community. The vascular outpatient clinic is an ideal place for the identification of patients with hypercholesterolaemia. Potentially, the vascular clinic is also has an important contribution to make in monitoring therapy and in the primary and secondary prevention of coronary heart disease. A cardiovascular risk evaluation and serum lipid measurement should be a compulsory part of any outpatient vascular assessment. The vast majority of patients with intermittent claudication already have an indication for lipid lowering therapy irrespective of any effect this may have specifically on their peripheral arterial disease. It is therefore unlikely that any placebo-controlled study trial could ever take place to specifically assess the effects of lipid lowering in peripheral vascular disease. The answer to the question ``should all claudicants be on a statin?'' is probably ``yes''. Rather than asking ``if''
Eur J Vasc Endovasc Surg Vol 25, April 2003
claudicants require statin therapy we should be probably be concentrating on the issue of ``how low'' we should get the cholesterol for maximum benefit.
References 1 Shepherd J, Cobbe SM, Ford I et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia. N Engl J Med 1995; 333: 1301±1307. 2 Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994; 344: 1383±1389. 3 Leng GC, Price JF, Jepson RG. Lipid-lowering for lower limb atherosclerosis (Cochrane Review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software. 4 Leng GC, Fowkes FGR. The epidemiology of peripheral arterial disease. Vasc Med Rev 1993; 4: 5±18. 5 Winyard G. Standing Medical Advisory Committee Statement on the Use of Statins. London: Department of Health, 1997. (EL(97)41HCD750IP, Aug 1997.) 6 Scottish Intercollegiate Guidelines Network. Lipids and primary prevention of coronary heart disease. In: Edinburgh: Royal College of Physicians, 1999. (SIGN publication No 40.) 7 Downs JR, Clearfield M, Weis S et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. JAMA 1998; 79: 1615±1622. Accepted