Statins: balancing benefits, efficacy and safety.

Coronary heart disease (CHD) is the leading cause of death in the US. The risk of CHD is substantially increased in people with elevated levels of low-density lipoprotein cholesterol (LDL-C). The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are the most effective drug class for lowering LDL-C. Long-term prospective studies have shown that statin therapy significantly reduces the risk of CHD morbidity and mortality in patients without or with evidence of established CHD (primary and secondary prevention, respectively). In 1988, treatment guidelines were first issued by the National Cholesterol Education Program Adult Treatment Panel I (NCEP-ATP I), then revised in 1993 (ATP II), to provide recommendations for the prevention and management of high cholesterol in adults. Despite these guidelines, recent national surveys have shown that effective therapies are being under-utilised and they often fail to achieve LDL-C goals established by NCEP-ATP II. The reasons appear to be multifactorial but include issues related to efficacy, safety, the potential for adverse drug reactions, failure to prescribe appropriate medication or dose and noncompliance with therapy. In the first major update of NCEP guidelines in almost a decade, the current ATP III recommendations have placed an increased number of Americans in the high-risk category, inviting even more aggressive therapy and escalating the challenge of reaching NCEP goals. New statins that may have even greater efficacy and less potential for drug interactions may help address some concerns associated with the failure to achieve treatment goals.