Statin therapy: where are we? where do we go next?

Statin therapy reduces coronary artery disease morbidity and mortality in primary and secondary prevention trials including patients with elevated and average cholesterol levels. The association between reduction of total or low-density lipoprotein cholesterol and preventive benefit is well established. However, additional risk factors for coronary artery disease need to be incorporated into risk assessment to provide an accurate measure of global risk for use in lifestyle intervention and drug therapy guidelines. Assessment of outcomes in the Air Force/Texas Coronary Atherosclerosis Prevention Study primary prevention trial, which involved patients with average cholesterol levels and reduced high-density lipoprotein cholesterol (HDL-C), suggests the importance of on-treatment values of apolipoproteins B and A-I in predicting first major events in such a population. Other data, including trials of fibrate therapy showing reduction in coronary artery disease events, support the importance of triglycerides and HDL-C in coronary artery disease risk. Challenges for future treatment guidelines include incorporation of emerging and novel risk factors into risk assessment, refinement of global risk measurement, and simplification for application to clinical practice.