CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Erin D. Michos, MD, MHS* and
Roger S. Blumenthal, MD
* Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Carnegie 568, 600 North Wolfe Street, Baltimore, Maryland 21287 (Email: emichos{at}jhmi.edu).
We thank Dr. Plonk for his letter regarding our recent publication (1). We agree that the incident rates for the primary end point in the JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) trial were overall moderate in this primary prevention trial (0.77 and 1.36 per 100 person-years of follow-up in the rosuvastatin and placebo groups, respectively) (2).
If we are interpreting Dr. Plonk's analyses correctly, he applied the 1.36% annual event rate found in the JUPITER placebo group equally across age groups in his table, only accounting for decreased life expectancy with age. However, the risk of cardiovascular events, many of which are nonfatal, also increases significantly with age (3). It appears that Dr. Plonk did not account for the increasing risk for the events with age when he stratified by age groups. Therefore, although the life expectancy is shorter at older ages, the risk of cardiovascular events is greater, which means the proportion that may benefit in the older age groups is likely greater than his table suggests.
The median age in the JUPITER clinical trial was 66 years, and the weighted median age group found in our NHANES (National Health and Nutrition Examination Survey) participants representative of the general U.S. population who met JUPITER eligibility was similar at 67 years (interquartile range 57 to 75 years; median age of 60 years for men and 74 years for women). Therefore, even when Dr. Plonk's estimates are used, a significant portion ( 20% to 25%) of eligible 55- to 75-year-old patients would likely benefit using this JUPITER strategy.
Furthermore, in JUPITER trial, there are >5,500 patients >70 years of age, and that subgroup had a highly significant 40% reduction in the trial primary end point (95% confidence interval: 0.45 to 0.82) with about a 2-year average follow-up time (Dr. Paul M. Ridker, personal communication, April 8, 2009). The purpose of our analyses was simply to estimate the number of U.S. adults who would meet the JUPITER eligibility criteria. By increasing decades of age (50 to 59 years, 60 to 69 years, 70 to 79 years, 80 to 89 years), we estimate by using NHANES data that 29.4%, 27.8%, 28.1%, and 14.7% respectively, would meet JUPITER eligibility criteria. Certainly the decision whether to initiate statin therapy should be made on a patient-specific basis, and statin therapy may not be indicated in those patients who are unlikely to benefit if their risk from other competing comorbities exceeds their cardiovascular risk. The role of how to incorporate high-sensitivity C-reactive protein levels in low-density lipoprotein cholesterol goal assignment will likely be addressed in the upcoming Adult Treatment Panel IV guidelines.
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1. Michos ED, Blumenthal RS. Prevalence of low low-density lipoprotein cholesterol with elevated high sensitivity C-reactive protein in the U.S.: implications of the JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) study J Am Coll Cardiol 2009;53:931-935.[Abstract/Free Full Text]2. Ridker PM, Danielson E, Fonseca FAH, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein N Engl J Med 2008;359:2195-2207.[CrossRef][Web of Science][Medline] 3. American Heart Association American Stroke Association Heart disease and stroke statistics 2007 update at-a-glance http://www.americanheart.org/downloadable/heart/1166712318459HS_StatsInsideText.pdf 2008Accessed June 15, 2009.
Related Article
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Most Would Fail to Benefit From JUPITER Intervention
- William M. Plonk, Jr
J. Am. Coll. Cardiol. 2009 54: 744.
[Full Text]
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