Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease

Background Percutaneous coronary revascularization is widely used in improv ing symptoms and exercise performance in patients with ischemic heart disea se and stable angina pectoris. In this study, we compared percutaneous coro nary revascularization with lipid-lowerin Methods We studied 341 patients with stable coronary artery disease, relati vely normal left ventricular function, asymptomatic or mild-to-moderate ang ina, and a serum level of low-density lipoprotein (LDL) cholesterol of at l east 115 mg per deciliter (3.0 mmol per liter) who were referred for percut aneous revascularization. We randomly assigned the patients either to recei ve medical treatment with atorvastatin, at 80 mg per day (164 patients), or to undergo the recommended percutaneous revascularization procedure (angio plasty) followed by usual care, which could include lipid-lowering treatmen t (177 patients). The follow-up period was 18 months. Results Twenty-two (13 percent) of the patients who received aggressive lip id-lowering treatment with atorvastatin (resulting in a 46 percent reductio n in the mean serum LDL cholesterol level, to 77 mg per deciliter [2.0 mmol per liter]) had ischemic events, as compared with 37 (21 percent) of the p atients who underwent angioplasty (who had an 18 percent reduction in the m ean serum LDL cholesterol level, to 119 mg per deciliter [3.0 mmol per lite r]). The incidence of ischemic events was thus 36 percent lower in the ator vastatin group over an 18-month period (P=0.048, which was not statisticall y significant after adjustment for interim analyses). This reduction in eve nts was due to a smaller number of angioplasty procedures, coronary-artery bypass operations, and hospitalizations for worsening angina. As compared w ith the patients who were treated with angioplasty and usual care, the pati ents who received atorvastatin had a significantly longer time to the first ischemic event (P=0.03). Conclusions In low-risk patients with stable coronary artery disease, aggre ssive lipid-lowering therapy is at least as effective as angioplasty and us ual care in reducing the incidence of ischemic events. (N Engl J Med 1999;3 41:70-6.) (C) 1999, Massachusetts Medical Society.