Dr. Suryono, SPJP

DISCUSSION
CRE/018/Apr13-Apr14/MF
1 Author | 00 Month Year Set area descriptor | Sub level 1
Treating dyslipidemia to target:
Key challenges and opportunity
with potential statin
Challenge is enormous
According to the WHO1
“An estimated 17.3 million people died from CVDs in 2008.”
“By 2030, almost 23.6 million people will die from CVDs.”
CHD remains the main cause of global mortality and a

major cause of morbidity and loss of quality of life.2
CVD: Cardiovascular disease
1. http://www.who.int/cardiovascular_diseases/en/
2. Medicographia. 2009;31:343-348.
Risk Factors for Coronary Heart Disease
Presence of several fixed risk factors signals the need for more intensive
lowering of LDL-cholesterol.
NCEP ATP III Executive Summary. NIH Publication.
Mayo Clin Proc. 2005;80:219–230.
Risk stratification scheme for CVD: ESC Guidelines
Rational for targeting high risk groups
• High risk is defined as the presence of two or more CHD

risk factors, such as age, family history, smoking status,
hypertension, high LDL-C and low HDL-C1
• The prevalence of additional risk factors, such as

obesity and diabetes, is rising.2
• Patients with more risk factors are at a higher risk of

experiencing a cardiovascular event.1
• The higher the number of risk factors, the higher the

probability of raised coronary intima-media thickness.2
Many of these risk factors are modifiable.
An aggressive control may prevent or at least postpone the cardiovascular events
in patients at risk.
1. NCEP ATP III. Circulation. 2002;106:3143–3421.

2. Kones R. Drug Design, Development and Therapy. 2011;5:325–380.
NCEP Interim Report: LDL-Cholesterol Goals
The third report of National Cholesterol Education Program (NCEP)

Expert Panel on detection, evaluation and treatment of high blood
cholesterol in adults (ATP III) - 2002
Circulation. 2004;110:227–239.
Intervention Strategies as a Function of
Total CV Risk and LDL-C
Choice of intervention largely depends on the number of CVD risk factors and LDL-C levels
LDL-C: Low density lipoprotein-cholesterol; CV: Cardiovascular Atherosclerosis. 2011:217S;S1–S44

DO ALL STATINS ARE
SAME ?
Rosuvastatin Demonstrated Significantly
Greater Reduction in Lipid Levels Compared to
Atorvastatin, Simvastatin and Pravastatin
Conclusion
Rosuvastatin (10-40 mg) had better efficacy in improving the lipid profile of patients with
hypercholesterolemia than milligram-equivalent doses of atorvastatin, and milligram-
equivalent or higher doses of simvastatin and pravastatin.
Jones PH, et al. Clin Ther. 2004;26:1388–1399

Rosuvastatin shows a Better Percentage Decrease in LDL-
Cholesterol compared to Atorvastatin
Wlodarczyk J, et al. Am J Cardiol. 2008;102:1654–1662.
Achievement of LDL -C Goals Across Dose Ranges
1. Jones PH, et al. Am J Cardiol. 2003;92:152–160.
VOYAGER: Achievement of Goal is Related to
Dose of Statin and Baseline LDL-C
Nicholls SJ, et al. Am J Cardiol. 2010;105:69–76
LUNAR: Rosuvastatin 40 mg Reduces LDL –C More than
Atorvastatin 80 mg in dyslipidemia with ACS Patients
*p=0.0219 vs. atorvastatin 80 mg
Pitt B, et al. Am J Cardiol. 2012;109:1239–1246.

Rosuvastatin 20 mg signficantly decreases the Apo B/Apo A1 Ratio
Compared to Atorvastatin 80 mg after 1 month of Treatment
Lablanchea J-M, et al. Arch Cardiovasc Dis. 2010;103:160–169.
Rosuvastatin is Highly Effective in Achieving Joint
European Goal Compared to Other Statin Treatments
Stender S, et al. Diabetes Obesity Metabolism. 2005;7:430–438.
Safety profile of rosuvastatin1
Safety profile of rosuvastatin was found to be tolerable in Taiwanese patients
SAE: Serious Adverse Event
ALT : Alanine Transaminase
ULN : Upper Limit Normal
1. Chiang CE, et al. J Chin Med Assoc. 2008;71:113–118.
Blood Sugar Changes with Rosuvastatin: Benefit of Aggressive
Lipid Lowering for High Risk Patients using Statin (SUBARU) Study
1. Kurabayashi M, et al. J Atheroscler Thromb. 2008;15(6):314–323.
Take home message
• Lower LDL-C levels are associated with lower CHD

mortality; the lower the better.1,2
• Early and aggressive diagnosis and treatment are

recommended.3
• Patients in high-risk categories require more intense

treatment.3,4
• Physicians’ adherence to treatment guidelines and

patients’ compliance to treatment may influence the
outcomes of the therapy.5
1. Exp Opin Emerg Drugs. 2004;9(2):269–279. 2. N Engl J Med. 2005;352:1425–
1435. 3. NCEP ATP III. Circulation. 2002;106:3143–3421. 4. Eur J Cardiovasc
Prevent Rehabil. 2011; epub ahead of print. DOI: 10.1177/1741826710397100. 5.
Eur J Cardiovasc Prev Rehabil. 2012;19:541–550.
Take home message
• In patients with hypercholesterolemia1

• In high-risk patients both with and without metabolic syndrome,
rosuvastatin at low dose provides significant advantages in goal
achievement and lipid lowering compared to other statins.
• Rosuvastatin had better efficacy in improving the lipid profile
compared to atorvastatin, simvastatin and pravastatin.
• In patients with non-diabetic metabolic syndrome2

• Low-dose rosuvastatin is significantly more effective than low-dose
atorvastatin in reducing LDL-C levels (especially in those with
lower NCEP ATP III target level goals).
• In patients with recent ACS3

• Rosuvastatin significantly decreased the apo B/apo A-1 ratio at 1
month compared with atorvastatin.
• Rosuvastatin 40 mg reduces LDL-C more than atorvastatin 80 mg
1. Stender S, et al. Diabetes Obesity Metabolism. 2005;7:430–438. 2. Park J-S, et al. Korean J Intern Med.
2010;25:27–35. 3. Lablanchea J-M, et al. Arch Cardiovasc Dis. 2010;103:160–169. 4. Pitt B, et al. Am J Cardiol.
2012;109:1239–1246.
THANK YOU
Management of Hypercholesterolemia Management of
Hypercholesterolemia Remains Suboptimal Remains Suboptimal
Difficult to reach goals with increasing level of risk
Results from Pan-Asian CEPHEUS
Survey conducted in eight

Asian countries with 7281
patients on lipid-lowering
therapy for 3 months
• 49% of patients overall
reached target LDL-C level
• Achievement of goal was
dependent on risk category
Increasing the cardiovascular

risk level decreases the
probability of attaining
respective LDL-C goals
1.Park JE, et al. Eur J Cardiovasc Prev Rehabil. 2011 Mar 7 [epub ahead of print] DOI: 10.1177/1741826710397100.
2.National Heart, Lung, and Blood Institute. Bethesda, MD; 2001. NIH Publication 01-3670.
PAN-ASIAN CEPHEUS Study:
Follow-up of patients not achieving LDL-C goals
Park JE, et al. Eur J Cardiovasc Prevent Rehabil. 2011; epub ahead of print. DOI:
10.1177/1741826710397100.
Percentage of Patients Achieving LDL-C Goals Recommended by
the 2004 Updated NCEP ATP III* Guidelines1
Percentage of patients achieving LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines
For patients in Hong Kong, the treatment goal attainment rate was 82.9% while patients in other countries had very
low LDL-C attainment rate (31.3–52.7%).
1. Park JE, et al. Eur J Cardiovasc Prevent Rehabil. 2011; epub . DOI:
10.1177/1741826710397100.
Balance between Incident Diabetes and Cardiovascular
Benefits with Statins1
Reduction in 5.4 cardiovascular

events per 255 patients treated for 4
years
One additional case of diabetes per 255

patients taking statin therapy for 4 years
1. Sattar N, et al. Lancet. 2010;375(9716):735–742.

Dr. Suryono, SPJP

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DISCUSSION

According to the WHO1

“An estimated 17.3 million people died from CVDs in 2008.”

CHD remains the main cause of global mortality and a

• High risk is defined as the presence of two or more CHD

• The prevalence of additional risk factors, such as

• Patients with more risk factors are at a higher risk of

• The higher the number of risk factors, the higher the

1. NCEP ATP III. Circulation. 2002;106:3143–3421.

The third report of National Cholesterol Education Program (NCEP)

LDL-C: Low density lipoprotein-cholesterol; CV: Cardiovascular Atherosclerosis. 2011:217S;S1–S44

Jones PH, et al. Clin Ther. 2004;26:1388–1399

Pitt B, et al. Am J Cardiol. 2012;109:1239–1246.

• Lower LDL-C levels are associated with lower CHD

• Early and aggressive diagnosis and treatment are

• Patients in high-risk categories require more intense

• Physicians’ adherence to treatment guidelines and

• In patients with hypercholesterolemia1

• In patients with non-diabetic metabolic syndrome2

• In patients with recent ACS3

Difficult to reach goals with increasing level of risk

Results from Pan-Asian CEPHEUS

Survey conducted in eight

Increasing the cardiovascular

Reduction in 5.4 cardiovascular

One additional case of diabetes per 255

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