A trial dubbed JUPITER made a big splash at the American Heart Association meeting in November 2008. On the surface, its results support wider use of statin drugs among people with normal cholesterol levels and more widespread testing for C-reactive protein (CRP). But, there's more to the story.
Exploring the details
JUPITER included nearly 18,000 volunteers at prime heart attack ages — men ages 50 and older, women 60 and older. None had high cholesterol. In fact, the average LDL was just over 100 mg/dL, a level most doctors would congratulate their healthy patients for achieving. None had ever been diagnosed with heart disease, either, though a fair number were smokers, or overweight, or had high blood pressure. The one "metabolic fault" shared by all of the volunteers was a high CRP. This protein reflects the amount of inflammation in the body, some of it generated by atherosclerosis (plaque buildup in the inner lining of an artery).
The volunteers who took 20 mg of Crestor, a powerful statin, every day for nearly two years did better than those taking a placebo. Their average LDL plummeted from 108 mg/dL to 55 (that's less than half of what is considered normal), while the average LDL in the placebo group hovered around 108. More important, the statin group had about 50% fewer heart attacks and strokes than the placebo group. Although that reduction sounds really impressive, in absolute terms it represents a reduction from 1.5% of participants in the placebo group to 0.7% in the Crestor group. Side effects like muscle pain were the same in both groups.
The trial's most important message is that many factors — not just high cholesterol — can identify individuals most likely to benefit from a statin and other risk-reducing strategies.
There's no question that we need new ways to identify people with hidden heart disease. Is CRP a "new way"? It makes the most sense for individuals at intermediate risk of heart disease. In this group, CRP information might tip the balance to, or from, starting statin therapy. The test isn't needed in people at high risk, most of whom should be taking a statin anyway, and we still don't know about its value in people at low risk.
Most older Americans have some artery-threatening plaque. If statins cost pennies a day and were 100% safe, then it might be a good idea for all adults to take one to stabilize their plaque. But statins cost real money — a year's supply of Crestor or another name-brand statin can top $1,200. They can cause aches and pains and, in rare cases, can damage muscle. They've also been linked to memory loss, though this, too, is uncommon.
In people with heart disease or at high risk for it, taking a statin makes sense, even when LDL is in the normal range. JUPITER provides clues as to which seemingly healthy individuals might also benefit from a statin: those with high CRP. Stay tuned — new guidelines are sure to follow.February 2009