Half of all strokes and myocardial infarctions occur in people who appear healthy and have cholesterol levels that would currently be untreated with statins. That’s why the JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) made such a splash when published in the NEJM last year (NEJM 2008;359:2195-2207).

The study was performed in patients who’d never experienced any cardiac events and weren’t at high risk. But they did have high levels of C-reactive protein, an inflammatory marker associated with cardiovascular (CV) risk. The 17,802 patients who qualified for this trial were randomized to receive rosuvastatin or a placebo. The study’s results were so promising that it was stopped early, after a mean of only two years’ follow-up. The rate of adverse CV events was 0.77 per 100 person-years in the rosuvastatin group and 1.36 in the placebo group.

Moreover, rosuvastatin lowered not only cholesterol and triglyceride levels, but also C-reactive protein. Of note, the two groups had the same rate of serious adverse events, and the same low rate of myopathic events.

Statins for all?

These extremely positive results suggest the time has come to begin considering patients for statin therapy who wouldn’t normally qualify. Rosuvastatin, when given to patients without a history of cardiovascular disease and with normal LDL-C but high CRP levels, appears beneficial in delaying or averting a first CV event.

Measuring CRP may be most useful in asymptomatic individuals who have an intermediate level of CVD risk, based on standard clinical risk markers. For example, older patients who have normal lipids, but higher BMI and blood pressure. The average JUPITER subject had a BMI of 28.3 with a blood pressure of 134/80, and these would serve as a good starting point.

It’s still important to use clinical judgement when prescribing statins to patients. The JUPITER study has its limits, especially the short duration of follow-up. But it adds to the evidence that patients at risk for vascular diseases should aim for even lower cholesterol levels, when it can be done safely and when the patient has enough time to experience the benefits. In fragile patients with advanced renal failure or severe CHF, it’s too late in the natural history for cholesterol lowering to help much.