Intensified Lipid-Lowering Therapy in Coronary Heart Disease: Is the Concept of “the Lower the Better” Evidence Based?

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Lipid-lowering therapy for secondary and primary prevention of atherosclerotic coronary heart disease is well established [1, 2]. All current guidelines support statin treatment in high-risk patients, especially in type 2 diabetes patients [3]. Apparently, the beneficial results of statin therapy suggest an almost linear relationship between the degree of low-density lipoprotein cholesterol (LDL-C) reduction and the relative risk of cardiovascular disease. This is, however, controversial because all recommendations are based on clinical trials that examined fixed doses of statins. In none of the trials has a gradual titration of lipid therapy to the proposed LDL goals been examined. In this respect, valuable results are given by the Heart Protection Study (HPS) trial, as all participants in this trial received 40 mg of simvastatin before randomization. The investigators measured each participant’s biological response to statin therapy. By giving all study participants a brief period of