New research from over 223,000 patients published in the Primary Care Cardiovascular Journal (PCCJ)1, suggests that total cholesterol (TC) levels in statin-treated UK patients are higher than that of the general population. The recent Health Survey for England (HSE 2006) 2 found that the mean TC was 5.3 mmol/L in men and 5.4 mmol/L in women. This is in contrast to the average TC of 6.3mmol/L in the statin-treated population from this retrospective GP database analysis of The Health Improvement Network (THIN).
Cholesterol levels are an important determinant of cardiovascular risk. The UK is already known to have one of the highest average cholesterol levels in the world contributing to the 275,000 heart attacks each year, making coronary heart disease (CHD) the nation's biggest killer3. It is estimated that approximately 46% of deaths may be attributable to raised cholesterol4. The Cholesterol Treatment Trialists (CTT) study found that lowering low density lipoprotein (LDL) cholesterol with statin therapy from 4 mmol/L to 3 mmol/L reduces the risk of major coronary events by about 23%5.
Given the number of patients prescribed statins, the range of statins currently available and the fact that cholesterol targets are incorporated within the National Service Framework (NSF), it is important that assessments of the impact of prescribing strategies in achieving treatment targets are informed by appropriate baseline cholesterol data. These new data show that baseline cholesterol levels in the statin-treated population were highest in the primary prevention population (6.57mmol/L) and lowest in patients with both cardiovascular disease and diabetes (5.79mmol/L).
These findings highlight differences in mean baseline total cholesterol (TC) measurements across statin-treated patient groups. The highest mean TC found in the primary prevention population reflects current practice in primary care where high pre-treatment cholesterol is a criteria for statin initiation. On the contrary, statins are initiated in secondary prevention patients regardless of their baseline cholesterol because they are rightly considered to be at higher risk of suffering from a subsequent cardiovascular event.
Dr Seleen Ong, Cardiovascular Medical Advisor at Pfizer and one of the lead authors of the study commented: "Differential guidance on the management of lipids currently exists with regard to recommended treatment strategies - for example, those with established cardiovascular disease and those with Type 2 diabetes. However, different patients require different levels of cholesterol lowering, dependent upon their individual degree of cardiovascular risk. These new data will provide clinicians with a new benchmark in each of these patient populations from which to assess progress to evidence-based treatment targets".
Dr Alan Begg, a GP based in Dundee, commented: "In order to reach quality targets GPs need to retain the ability to sequence therapy, possibly using other more potent statins or with the addition of other cholesterol lowering drugs. If the only statin that can be prescribed is one with a low acquisition cost but with less potency then the risk reduction potential may be limited. A standard fixed-dose statin with a low acquisition cost might not be sufficient in individual patients to maximise their risk reduction".
Policy-makers are increasingly wanting to explore specific statin treatment scenarios. These new data provide an important reference point for analyses of different statin-prescribing strategies in defined patient groups at different levels of cardiovascular risk in order to drive improved CV disease outcomes.
Data from The Health Improvement Network (THIN) were used to identify statin users. The baseline cholesterol measurement prior to the first prescription of a statin was recorded for 223,058 statin-treated patients, stratified by cardiovascular risk.
Patient groups included: patients taking statins who do not have established cardiovascular disease (CVD) or diabetes (primary prevention patients); patients with established CVD but no diabetes; patients with diabetes but no evidence of CVD; patients with both diabetes and CVD. Baseline measurements reflect the last serum TC test prior to the first prescription of a statin.
Table 1. Summary of baseline mean TC levels (mmol/L), by population sub-group
|Diabetes + no CVD||40,055||5.93||5.80||1.15|
|CVD + diabetes||10,480||5.79||5.67||1.21|
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1.Thompson R, et al. Measurement of baseline total cholesterol: new data from The Health Improvement Network (THIN) database. Primary Care Cardiovascular Journal 2008; 1; 107 - 111
2. Health Survey for England (2006) (PDF) (accessed 25 July 2008)
3. Department of Health: Coronary Heart Disease (accessed 17 July 2008)
4. Magnus P, Beaglehole R. The real contribution of the major risk factors to the coronary epidemics: time to end the "only-50%" myth. Arch Intern Med 2001; 161: 2657-60
5. Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins. The Lancet 2005; 366; 1267 - 1278
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