Statins and mortality.

In this issue Simes et al. present pooled estimates for mortality from the Pravastatin Pooling Project (PPP). The two secondary prevention studies and the primary prevention trial included in the PPP enrolled together about 20 000 men and women aged 45–75 years with or without established coronary artery disease and a wide range of baseline lipid levels. As compared to placebo, in those allocated to pravastatin, LDL cholesterol was lowered by 24% and triglycerides by 9%, whereas HDL cholesterol increased by 5%. After a follow-up period of about 5 years, in the pravastatin arm, there was a relative risk reduction of 20% for total mortality, and 24% for coronary heart disease mortality. Moreover, non-cardiovascular mortality was non-significantly reduced by 12%, with no evidence for an increase in specific deaths. There was no statistical evidence for differences in the relative risk reduction between primary and secondary prevention, different age strata, or sex. Among cardiovascular disease endpoints, the risk reduction was most impressive for fatal definite MI, with a risk reduction of 50%. Because of the similar relative risk reduction across different strata, the absolute risk reduction of pravastatin use was largely driven by the underlying mortality risk. These results corroborate findings of single statin trials and results of pooled combined cardiovascular end-points. Compared to other interventions and medications after myocardial infarction, statins are among the most effective therapies in the reduction of subsequent cardiovascular events and mortality. Moreover, the results confirm that the relative risk reduction for different end-points is quite stable across different strata of baseline risk. As is known from many previous studies, the risk of mortality is several-fold increased among patients with established coronary heart disease, and accordingly, these patients derive the greatest benefit from statins with respect to absolute risk reduction. Despite the known large benefits, many patients with established