Reversal of Coronary Atherosclerosis

There is a large burden of disease associated with cholesterol buildup in the arteries supplying blood to the heart. As a family physician, I often see people with this condition, and have great interest in any new developments in how to prevent or treat the disease.

Pharmaceutical therapy has been show to reduce the risk of suffering a serious cardiac event. Now, with newer imaging techniques, we can visually demonstrate regression of cholesterol plaques in the coronary arteries. Intravascular ultrasonography is one technique that was recently utilized in a study looking at two different pharmaceutical regimens. The research was published New England Journal of Medicine [2011]. Over a thousand people participated in the study.

One of the two agents studied was rosuvastatin, which is marketed under the brand name Crestor. The other agent studied was atorvastatin. Both medications are types of statins. These particular agents were chosen because they are effective at lowering low-density lipoprotein (LDL) cholesterol. The question was whether or not plaque regression in the coronary arteries could be demonstrated by intravascular ultrasonography after 2 years on statin therapy. The study looked at people 18 to 75 years old. The average age was 58.

A reduction in disease progression was seen in the majority of people. The reduction in percent plaque volume was small, but statistically significant. Although both pharmaceutical agents were effective, there was some evidence that rosuvastatin may result in greater disease progression. First of all, the reduction in LDL cholesterol on maximal rosuvastatin therapy was greater than that achieved by atorvastatin (62.6 mg/dL versus 70.2 mg/dL). Secondly, the secondary end-point measured, total atheroma volume (TAV), was reduced more by rosuvastatin than atorvastatin. Finally, a greater proportion of patients on rosuvastatin had disease regression as measured by TAV (71.3% versus 64.7%). Both agents appeared to be well tolerated. Differences in clinical outcomes were not measured due to the low number of events. The overall annual rate of myocardial infarction was 0.8%, the annual rate of stroke 0.2% and cardiovascular death 0.15%.

COMMENT: Rosuvastatin may be a superior agent in many people. But remain skeptical because the study was funded by a pharmaceutical company. Sometimes this financial influence results in misleading results and misinterpretations, resulting in a medical myth. Nevertheless, I do not see evidence of undue bias in this study.

I am most impressed by the serious event rate seen. Despite being in a research study, undergoing intensive therapy, and receiving ongoing treatment at some of the best medical institutions, the annualized serious cardiovascular event rate still remained at approximately 1%. Pharmaceutical therapy appears to slowly regress the disease, however, risk remains high. It is important to note that many people with coronary atherosclerosis have concurrent health issues that potentially could be treated with lifestyle changes. For example, about a third of the patients in this study smoked. We need to learn more effective ways to improve dietary habits, exercise levels, and quit smoking.

REFERENCE

Nicholls SJ, Ballantyne CM, Barter PJ, Chapman MJ, Erbel RM, Libby P, Raichlen JS, Uno K, Borgman M, Wolski K, Nissen SE. Effect of two intensive statin regimens on progression of coronary disease. N Engl J Med. 2011 Dec 1;365(22):2078-87. Epub 2011 Nov 15.