Can an 85 year old black female with CAD, non-Q wave MI x 2 with high cholesterol benefit from antidyslipidemic therapy?
March 7, 1997
Clinical Scenario: 85 year old black female with known CAD, non-Q wave MI x 2, AoV replacement on low dose coumadin secondary to AVMs, TIAs admitted for angina and r/o for MI with cholesterol 303, LDL 236, TG 144 and HDL 33.
Bottom Line: Treating dyslipidemia in patients with multiple atherosclerosis risk factors but no known coronary atherosclerosis (primary prevention), patients with known coronary atherosclerosis(secondary), or patients with previous myocardial infarction (tertiary) prevents morbidity and mortality from cardiovascular disease, with the most benefit accruing to high risk patients. Few studies included large numbers of women or older persons. Benefits appeared to extend to persons > 65, but with less clearly defined benefits to women. More studies including women are needed.
Evidence: Meta-analysis of randomized clinical trials, all single blind and most double blind, with benefits quantified in "number needed to treat" (NNT) as an estimate of benefit.
|Primary Prevention||Event Prevented||NNT|
|(4.8 years treatment)||All cause death||190|
|Prevention studies||(Years)||Nonfatal MI||All cause death||+/-|
|All Studies||4.9||16||37||-18% chol|
|New Studies||4.2||15||41||-32% LDL/+8% HDL|
|Diet Only||4.8||15||NS||-17% chol|
|HMG-CoA||4.1||15||37||-32% LDL/+7% HDL|
1. Studies included primarily men (92% primary prevention, 89% secondary and tertiary prevention); more studies involving women are needed. Of interest, women outnumber men among older personswith high cholesterol.
2. Time-to-event curves are needed to assess when benefit can be expected from duration of therapy.
3. Inclusion/exclusion criteria are needed to evaluate study applicability to patient populations, as well as end point definition analysis and effect.
4. Predictions/assessments of lifespan and quality of life are relevant in management of hypercholesterolemia.
Rembold CM. Number-Needed-To-Treat Analysis of the Prevention of Myocardial Infarction and Death by Antidyslipidemic Therapy. J Fam Prac 1996; 42:577-86.
Spence JD. Meta-analysis: Antidyslipidemic therapy Drevents myocardial infarction and death. ACP Journal Club 1997;126(1):4