Rosuvastatin on par with atorvastatin in CAD

Rosuvastatin is as effective as atorvastatin for the composite outcome of all-cause death, myocardial infarction (MI), stroke, or any coronary revascularization at 3 years in adults with coronary artery disease (CAD), according to the secondary analysis of the LODESTAR trial.

In addition, “[r]osuvastatin treatment was associated with lower low-density lipoprotein cholesterol levels (LDL-C), but it also carried a higher risk of new-onset diabetes mellitus requiring antidiabetics and cataract surgery, compared with atorvastatin treatment,” the researchers said.

This randomized, open-label, multicentre trial was conducted in 12 hospitals in South Korea from September 2016 to November 2019. A total of 4,400 adults with CAD were assigned to receive either rosuvastatin (n=2,204) or atorvastatin (n=2,196). The researchers then measured the primary outcome of a composite of all-cause death, MI, stroke, or any coronary revascularization at 3 years.

Safety outcomes were also assessed, including new-onset diabetes, hospital admissions due to heart failure, deep vein thrombosis or pulmonary thromboembolism, endovascular revascularization for peripheral artery disease, aortic intervention or surgery, end-stage kidney disease, treatment discontinuation due to intolerance, cataract surgery, and laboratory-detected abnormalities.

Of the participants, 4,341 (98.7 percent) completed the trial. The mean daily doses of the study drugs at 3 years were 17.1 and 36.0 mg in the rosuvastatin and atorvastatin groups, respectively (p<0.001). [BMJ 2023;383:e075837]

The primary outcome was observed in 189 participants (8.7 percent) treated with rosuvastatin and 178 (8.2 percent) with atorvastatin (hazard ratio [HR], 1.06, 95 percent confidence interval [CI], 0.86‒1.30; p=0.58). During treatment, the mean LDL-C level was 1.8 mmol/L in the rosuvastatin group and 1.9 mmol/L in the atorvastatin group (p<0.001).

In terms of safety, the incidence of new-onset diabetes requiring initiation of antidiabetic medication was higher in the rosuvastatin group (7.2 percent vs 5.3 percent; HR, 1.39, 95 percent CI, 1.03‒1.87; p=0.03), as was cataract surgery (2.5 percent vs 1.5 percent; HR, 1.66, 95 percent CI, 1.07‒2.58; p=0.02). Other safety endpoints were comparable between the two treatment arms.

High-intensity statin

“In clinical practice, appropriate decisions for statin type as well as statin intensity are important,” the researchers said. “[H]owever, only rosuvastatin and atorvastatin can offer both the high-intensity and moderate-intensity statin treatment usually required by people with CAD to intensively lower their LDL-C levels.” [J Am Coll Cardiol 2019;73:e285-350; Eur Heart J 2020;41:111-188; JAMA 2023;329:1078-1087]

Earlier studies have reported the benefits of using either rosuvastatin or atorvastatin in CAD patients. [N Engl J Med 2005;352:1425-1435; N Engl J Med 2004;350:1495-1504; Lancet 2022;400:380-390]

“However, only the SATURN trial directly compared the effects of rosuvastatin and atorvastatin treatment in people with CAD,” the researchers said. [N Engl J Med 2011;365:2078-2087]

Of note, the SATURN trial focused on the effects of the highest doses of rosuvastatin and atorvastatin on the progression of coronary atherosclerosis rather than clinical outcomes. It also assessed fewer participants (n=1,039) and had a shorter follow-up time (2 years) than the current study.

“Our randomized study, however, compared the effects of rosuvastatin and atorvastatin treatment in terms of a composite of all-cause death, MI, stroke, or any coronary revascularization in 4,400 patients with CAD during 3 years of follow-up,” the researchers said.

“The results show that rosuvastatin was associated with greater efficacy in reducing LDL-C levels throughout the study period, which is in line with a previous meta-analysis showing the superiority of rosuvastatin over atorvastatin in lowering LDL-C levels,” they added. [Am J Cardiol 2010;105:69-76]