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American Journal of Kidney Diseases

Focused Atorvastatin Therapy in Managed-Care Patients With Coronary Heart Disease and CKD

Published:February 12, 2009DOI:https://doi.org/10.1053/j.ajkd.2008.11.025

      Background

      This post hoc analysis of the Aggressive Lipid-Lowering Initiation Abates New Cardiac Events (ALLIANCE) Study investigates the effect of focused atorvastatin therapy versus usual care on cardiovascular outcomes in patients with coronary heart disease (CHD) with and without chronic kidney disease (CKD).

      Study Design

      Prospective randomized open-label; median follow-up, 54.3 months.

      Setting & Participants

      Managed care or Veterans Affairs facilities; 2,442 patients with CHD with dyslipidemia; mean age, 61.6 years.

      Intervention

      Focused atorvastatin therapy to a low-density lipoprotein cholesterol goal of less than 80 mg/dL or maximum dose of 80 mg/d versus usual care as deemed appropriate by patients' regular physicians.

      Predictor

      Baseline estimated glomerular filtration rate (eGFR) calculated using the Modification of Diet in Renal Disease Study equation of less than 60 mL/min/1.73 m2 (patients with CKD) and 60 mL/min/1.73 m2 or greater (patients without CKD).

      Outcomes & Measurements

      The primary end point was time to first cardiovascular event. Change from baseline eGFR was assessed in 1,768 patients with follow-up renal data.

      Results

      At baseline, 579 patients (23.7%) had CKD: 31.6% of these patients experienced a primary cardiovascular event during the study versus 23.6% of patients without CKD (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.18 to 1.68; P < 0.001). Compared with usual care, atorvastatin therapy reduced the relative risk of a primary outcome by 28% in patients with CKD (HR, 0.72; 95% CI, 0.54 to 0.97; P = 0.02) and 11% in patients without CKD (HR, 0.89; 95% CI, 0.74 to 1.07; P = 0.3) (P for treatment by CKD interaction = 0.2). There was no decrease in eGFR in atorvastatin-treated patients during the course of the study.

      Limitations

      Follow-up of atorvastatin patients was restricted to every 6 months; interim data were unavailable for usual-care patients.

      Conclusions

      Patients with CHD and CKD are at increased risk of cardiovascular events. Compared with usual care, focused atorvastatin treatment decreased cardiovascular risk for established patients in real-world settings, with no significant difference in treatment effects observed between patients with and without CKD.

      Index Words

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      Linked Article

      • Statin Effects in CKD: Is There a “Point of No Return”?
        American Journal of Kidney DiseasesVol. 53Issue 5
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          A higher low-density lipoprotein (LDL) cholesterol level is strongly associated with increased risk of coronary heart disease (CHD) in populations without kidney disease. Statin therapy can reduce the risk of major coronary events, coronary revascularization, and stroke by about one-fifth per 1 mmol/L decrease in LDL cholesterol, largely irrespective of the initial lipid profile.1 A similar effect is seen in people with diabetes mellitus, which has led to the conclusion that statin therapy should be considered for all individuals with diabetes irrespective of whether vascular disease has developed and irrespective of lipid profile.
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