Expert panel: African Americans deserve greater statin access

Lipid Disorders

Despite their safety and efficacy, HMG-CoA reductase inhibitors (statins) are underutilized in the African American population with dyslipidemia, according to a review in the March/April 2005 issue of the ABC Digest of Urban Cardiology.

African Americans are one group for whom statins should play a key role in coronary heart disease (CHD) risk re-

duction because CHD affects African Americans disproportionately, writes the ABC expert panel, led by Karol E. Watson, MD, PhD, director of the University of California, Los Angeles, Center for Cholesterol and Hypertension Management. According to the Centers for Disease Control, African Americans have earlier and greater mortality rates from CHD compared with most other US ethnic and racial groups.

“Statins are generally very well tolerated, and serious adverse effects are rare,” write the authors. “Currently, there appears to be no discernible difference between the statins in the range or severity of adverse effects, although experience is more limited with rosuvastatin.” They note that transaminase elevations may occur, but their clinical significance is uncertain and that progression to liver failure “is exceedingly rare with statins, if in fact it ever happens.”

The rate of myotoxicity with statins is 1% to 7%. The risk of myopathy appears to be increased by higher statin doses, certain medications taken concomitantly, or the presence of renal impairment. Rhabdomyolysis and myositis are rare, accounting for 0.1% of statin-related adverse effects.

“The few cases of adverse events in patients being prescribed statin therapy have been unfairly exaggerated,” according to the expert panel. “Fortunately, the one compound that was associated with an unusually high rate of serious side effects, cerivastatin, is no longer available. Statins should be prescribed with confidence.”

The clinical trial experience with statins in African Americans is limited, but provides evidence of clinical efficacy. In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, African Americans made up 38% of the study population. In this group, pravastatin was associated with a significant reduction in the rates of myocardial infarction and stroke compared with usual care, whereas the reduction in these events with pravastatin in the overall population did not reach statistical significance.

Two trials have tested the lipid-modifying effects of statins exclusively in African Americans. In one study of 245 patients, pravastatin decreased low-density lipoprotein (LDL) cholesterol by 26% but also decreased high-density lipoprotein cholesterol by 0.5%. The African American Rosuvastatin Investigation of Efficacy and Safety compared the effects of mg-equivalent doses of rosuvastatin and atorvastatin in 774 African Americans over 6 weeks. Rosuvastatin, 10 or 20 mg, was associated with a reduction in LDL cholesterol of 37% and 46%, respective-ly, which was significantly greater than the 32% and 39% reductions in LDL cholesterol obtained with atorvastatin, 10 or 20 mg.

The expert panel calls for greater efforts to ensure access and availability of statins to populations at highest risk, including African Americans.