Author + information
- Vivencio Barrios, MD, PhD⁎ ( )( and )
- Carlos Escobar, MD, PhD
- ↵⁎Department of Cardiology, Hospital Ramón y Cajal, Ctra. De Colmenar km 9.100, 28034 Madrid, Spain
We read with interest the article by Cleland et al. (1) about whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) could be used to identify the degree of severity of heart failure at which statins become ineffective in the CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure) trial. Although many trials have demonstrated that statins reduce cardiovascular morbidity and mortality in many patients with ischemic heart disease, this does not seem to occur in those with ischemic heart failure, as the CORONA trial showed (2). As a result, there must be a cutoff point at which treatment with a statin becomes futile. In this study, the investigators demonstrated that patients in the lowest tertile of NT-proBNP had the best prognosis and, if assigned to rosuvastatin rather than placebo, had a greater reduction in the primary end point (hazard ratio: 0.65; 95% confidence interval: 0.47 to 0.88) than patients in the other tertiles (p = 0.0192). As a consequence, patients with heart failure due to ischemic heart disease who had NT-proBNP values <103 pmol/l (868 pg/ml) may benefit from rosuvastatin (1).
However, this seems to occur not only in the ischemic heart disease, but in the overall cardiovascular continuum, and the different results obtained with rosuvastatin in the different scenarios of several randomized clinical trials clearly exemplify it (3). Cardiovascular disease is a continuum, from risk factors to organ damage and finally to overt clinical cardiovascular disease and end-stage renal disease. Although it is very relevant to control all cardiovascular risk factors along the continuum, the beneficial effects of therapy are not the same, depending on the stage at which the treatment is started. Thus, if statins are prescribed at earlier stages, the improvement in cardiovascular prognosis will be markedly higher than in later stages (3). For example, in the JUPITER trial (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) (4), which included patients without cardiovascular disease but with elevated high-sensitivity C-reactive protein levels, the benefits of treatment with rosuvastatin were outstanding. However, at very advanced stages such as heart failure (CORONA) (2) or at end-stage renal disease (AURORA [A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events]) (5), the benefits were very modest or even null. However, even at advanced stages, as Cleland et al. (1) reported, not all the patients are the same. Because mortality is very high, all the approaches aimed at differentiating which patients will benefit more from available therapies are crucial. In this case, NT-proBNP values could likely be used as a good predictor of the clinical results with a statin therapy.
All these data emphasize that to really improve a cardiovascular prognosis, it is critical to start the treatment with statins as soon as possible in the cardiovascular continuum. If the therapy starts when a patient is already at end-stage disease, it is most likely too late.
Please note: Dr. Barrios is principal investigator of the CORONA trial and a member of the steering committee of CORONA and has received lecture fees and research grants by AstraZeneca.
- American College of Cardiology Foundation
- Cleland J.G.,
- McMurray J.J.,
- Kjekshus J.,
- et al.