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West of Scotland coronary presentation study in patients with raised cholesterol, was to reduce by 31% the risk of coronary events over a 6 year follow up.


A seminar on "Updates in Hyperlipidaemia Therapy" was held on 3 January 1997 at the Shangri-la Hotel. The speaker was Cardiologist, Professor Eugene Braunwald, Distinguished Hersey Professor of Medicine, Harvard Medical School, Faculty Dean for Academic Programmes of Brigham Women's & Massachusetts General Hospitals and the Co-Editor of Harrison's Principles of Internal Medicine. Dr Tan Hooi Hwa reports on the seminar organised by Singapore Cardiac Society and Endocrine & Metabolic Society of Singapore. 

This seminar focused on 1 of the 3 important trials published in the last 2 years on the effect of cholesterol reduction on cardiovascular events. They were: 

1.  4S Overall Survival (Scandinavian Simvastatin Survival Study) in patients with coronary heart disease (CHD) (Lancet 1994) and raised cholesterol level. (221 - 350mg%). The results showed that with a marked reduction of cholesterol, the mortality of patients, and the need for intervention (viz. Angioplasty and CABG), was reduced by 30% over a 5 year follow up. 

2.  West of Scotland, coronary presentation study in patients with raised cholesterol and no previous coronary heart disease, the effect of pravastatin monotherapy in lowering cholesterol, was to reduce by 31% the risk of  coronary  events  over  a  6  year  follow up.  This  study  was  conducted  in  a  male population   aged   45  -  64   with   cholesterol  > 252mg%. 

3.  CARE (Cholesterol & Recurrent Events) Study in North America. (New England Journal of Medicine, 1996). This was a secondary prevention trial in post myocardial infarction patients with average cholesterol levels. This study included males and females aged 21-75 years old (average 59 years), in a double blind trial lasting 5 years. 40mg pravastatin or placebo were given. 
 The plasma total cholesterol level was below 240mg% (mean 209) and LDL cholesterol was 115 to 174 mg% (mean 139). Approximately 15% of patient with acute myocardial infarction have cholesterol levels >240mg%. Therefore, those included in the CARE study represented the majority of patients with coronary heart disease. 

The result showed: 
1. 25% reduction of non-fatal MI/fatal CHD after 5 years, with no benefit in the first 2    years. 
2. 26% reduction in coronary bypass/angioplasty. 
3. 32% reduction in stroke. 
4. 37% reduction in fatal MI. 
5. In certain subgroups: 
    i. Diabetics showed a 25% reduction in coronary events. 
    ii. Women benefited more from the reduction in cholesterol. 
    iii. LDL-cholesterol level as a marker for the prediction of benefit. 
        < 125mg% - there appeared to be reduction in coronary events.   
        >  125mg% - there was a 29% reduction of CHD death or non-fatal AMI.   
        However, in non-fatal AMI, unpublished data showed that if there is a reduction of     
        25-30% of LDL-cholesterol, no matter at what level, the benefits are still there. 
    iv. The lower the HDL, the more obvious the benefit 
    v. Triglyceride levels: 
        > 172 - 350mg% - least benefit (8%)  
        120 - 170mg% - 20% risk reduction  
        < 120mg% - 42% risk reduction 

The presence of breast cancer: 1 patient in the placebo group and 12 in the pravastatin group could not be explained as due to the effect of drug, as 3 occurred in patient with previous breast cancer and 1 was ductal carcinoma and 1 occurred in a patient who took the drug for only 6 weeks. In Professor Braunwald's opinion, it was probably a random occurrence.