Christopher P. Cannon, MD is an Associate Professor of Medicine at Harvard Medical School in the Cardiovascular Division at Brigham and Women’s Hospital in Boston. He is a senior investigator of the Thrombolysis in Myocardial Infarction (TIMI) Study Group, and over the past two decades has been the principal investigator for 10 international clinical trials in the area of heart attacks and prevention. Recent trials include PROVE IT-TIMI 22, which showed that “lower is better” for cholesterol and changed international guidelines, and CLARITY-TIMI 28 which showed that giving heart attack patients clopidogrel (Plavix) can prevent future heart attacks. Cited one of the “Best Doctors in Boston,” Dr. Cannon has published more than 500 articles in the field of heart attacks and cardiovascular prevention, and is the author or editor of seven books, including The Complete Idiot’s Guide to The Anti-Inflammation Diet. He is also the new Editor-in-Chief of Cardiosource and a contributing editor at Cardiosmart.org.

Christopher Cannon--

The news was everywhere – a trial called JUPITER showed a dramatic reduction in heart attacks, stroke, and death using statins in people without a high cholesterol – but who had “inflammation.” Inflammation was measured using a simple blood test, C-reactive protein (CRP). When ‘otherwise healthy” people with no sign of heart disease took a strong statin – rosuvastatin (Crestor), they had a nearly 50% lower risk of heart attack or stroke and a 20% lower risk of dying – in just 2 years. Wow!

So – does this pertain to me? Do I need a CRP test to tell if I need a statin? (would be reasonable to ask your doctor). If I have a high CRP – I have inflammation – what is that? It has been described as irritation, or roughness inside the blood vessels – that make it more likely that cholesterol plaques (the blockages inside the blood vessels) will break open, and lead to a heart attack or stroke. What does this mean for my cholesterol? How low should mine be? (quick answer – the lower the better) All great questions!

So – some details on the study: JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) looked to see whether intensive statin therapy (Crestor 20 mg will lower your bad cholesterol – low density lipoprotein or LDL – by 50%) would decrease the risk of developing a first major cardiovascular events among people who do not have a high cholesterol (that is their LDL had to be less than 130 mg/dl), but who were nonetheless at increased risk due to a high hs-CRP (≥2 mg/L). The trial randomized 17,802 men ≥55 years and women ≥65 years with no prior cardiovascular disease or diabetes (in whom statins are currently recommended) to rosuvastatin 20 mg/day or placebo. When starting out, the median LDL-C was just 108 mg/dl and hs-CRP was 4.3 mg/L; LDL-C was reduced by half down to 55 mg/dl. hs-CRP was reduced by 37%.

Results

There was a highly significant 44% reduction in the incidence of the primary endpoint of any cardiac event – a heart attack, stroke, hospitalization for worsening chest pain (called unstable angina), need for angioplasty or bypass surgery, or cardiovascular death - compared with placebo(a highly significant difference p < 0.00001). In looking at how many people developed a cardiac event, it was about 8 for a 1000 patient years of follow-up in the treated group compared with more than 13 in the placebo group. There was a significant 65% reduction in nonfatal heart attacks, (p < 0.00001), 48% reduction in nonfatal stroke (p = 0.003), 46% reduction in need for angioplasty or bypass surgery (p < 0.0001), as well as a significant 20% reduction in all-cause mortality (10 vs. 12.5 deaths per 1000 patient-years p = 0.02). All subgroups of patients analyzed showed significant reductions in the primary endpoint, including women. These results from JUPITER provide compelling evidence regarding the benefits of statin therapy in persons without high cholesterol but who are at enhanced risk because of increased inflammation. It also reinforces of the benefits of lowering LDL cholesterol – in this case in otherwise healthy people.

So – this trial really reinforces the benefits of statins in preventing heart attacks, strokes, and death. It looked at a new group of patients, who have high CRP levels but not high cholesterol, and doctors will begin thinking about exactly what patient should be tested, and who should be treated. The trial also reinforces the benefit of statins in general – that they are well tolerated, and have significant benefits.

Can Inflammation be reduced without drugs?

This is a good question! While it is great to see benefits from medications – it is certainly reasonable to try to avoid medication. This is a perfect example where diet and exercise can play a key role. We recently published a book on an Anti-Inflammation Diet in the Complete Idiot’s Guide series – that discusses ways to reduce inflammation via altering your diet and lifestyle. The key message is that through (non-radical) changes in diet one can reduce intake of foods that promote inflammation (e.g. saturated fats) and increase intake of foods that reduce inflammation (e.g. omega-3 fatty acids like in salmon, or flax seeds. Also, just aiming to eating a balanced diet, with less processed foods will make a huge impact in reducing inflammation. There have been several studies showing reducing in hs-CRP with some diets – thus strong evidence to support the idea of modifying diet can help. So – we have more things that we can do to improve our heart health! Targeting the usual risk factors is one step, but reducing inflammation looks like a new way to prevent heart problems!

Related: The Truth About The Crestor Cholesterol Study

Update on Dec 2, 2008 by At Basil & Spice

Inform Link!

Reuters!