Statin Therapy in Primary Prevention: New Insights Regarding Women and the Elderly

events. 1 Therefore, the emphasis on primary and secondary prevention is imperative to provide high-quality and costeffective medical care that will improve survival and quality of life. Multiple studies have demonstrated a morbidity and mortality benefit in patients with established CVD treated with the lipid-lowering medications known as hydroxymethylglutaryl coenzyme A reductase inhibitors, or statins. 2‐6 A prospective meta-analysis conducted by the Cholesterol Treatment Trialists’ Collaboration included data from 90,056 patients in 14 randomized trials of statin treatment. They showed a 12% reduction in all-cause mortality per 39 mg/dl reduction in low-density lipoprotein cholesterol (p 0.0001), which reflected a 19% reduction in coronary mortality (p 0.0001). Statistically significant reductions were also observed in myocardial infarction, coronary heart disease (CHD) death, coronary revascularization, and fatal or nonfatal stroke. There was a 21% reduction for a composite of these end points. Reduction of low-density lipoprotein cholesterol by approximately 8 mg/dl in patients with preexisting CHD translated into 48 fewer participants sustaining major vascular events per 1,000 participants, compared to 25 fewer per 1,000 in participants with no CHD histories. Meta-analyses such as this have demonstrated the efficacy of statins and have influenced patient care by driving the inclusion of statins as part of the standard of care for patients with CHD, dyslipidemia, diabetes mellitus, and peripheral arterial disease. 7,8 The evident benefit of statin therapy for secondary prevention has in turn led to a greater emphasis on the use of statins in primary prevention. Most patients with atherosclerosis are asymptomatic, and half of all myocardial infarctions and strokes occur in patients with low-density lipoprotein cholesterol levels that are less than the currently recommended thresholds for treatment. In addition, the effect of statins and their role in primary prevention for women and the elderly have not been thoroughly evaluated. Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) allows clinicians to evaluate the effects of statin therapy for primary prevention of CVD in these 2 populations. 9 JUPITER enrolled 17,802 subjects (6,801 women) without histories of CHD, stroke, or diabetes who had lowdensity lipoprotein cholesterol levels 130 mg/dl and highsensitivity C-reactive protein (hsCRP) levels 2.0 mg/L. These subjects were randomized to rosuvastatin 20 mg/day versus placebo. Treatment with rosuvastatin in this low-risk population showed a 54% reduction in myocardial infarction, a 46% reduction in revascularization, and a 20% reduction in all-cause mortality compared to placebo. The trial was terminated early after a median of 1.9 years because of a significant treatment benefit in the overall study population. 9 Mora et al 10 recently conducted a gender-specific outcome analysis of JUPITER. At 12 months, the median changes in hsCRP and low-density lipoprotein cholesterol in treated women were 1.8 mg/L and 51 mg/dl, respectively. These decreases were similar to those observed for men in JUPITER. The relative risk reduction of the primary end point was similar and statistically significant in women (hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.37 to 0.80, p 0.002) and men (HR 0.58, 95% CI 0.45 to 0.73, p 0.001). Gender-specific differences included greater reductions in unstable angina and revascularization in women (HR 0.24, 95% CI 0.11 to 0.51) compared to men (HR 0.63, 95% CI 0.46 to 0.85 p for heterogeneity 0.01). The hazard risk for all-cause death was nonsignificantly reduced for women and men but was significant when the 2 were combined. This study clearly demonstrated the benefit of statin therapy for primary prevention in women classified