Doggrell Sheila A
Division of Health Practice, Auckland University of Technology, Northcote, Auckland, New Zealand.
Rev Recent Clin Trials. 2006 May;1(2):143-53. doi: 10.2174/157488706776876508.
Placebo-controlled clinical trials have shown that atorvastatin is beneficial in patients with myocardial ischemia, established coronary artery disease, hypertension and 3 other cardiovascular risk factors (e.g. left-ventricular hypertrophy, type 2 diabetes, smoking), and in diabetes, but not in patients with calcific aortic stenosis. Recently, intensive low density lipoprotein (LDL)-cholesterol lowering with atorvastatin 80 mg/day has been shown to have a greater clinical benefit than atorvastatin 10 mg/day in patients with coronary heart disease and one other high-risk factor (previous myocardial infarction, coronary revascularization or angina), and to be superior to moderate lipid lowering with pravastatin (40 mg/day) in patients with an acute coronary syndrome. However, a smaller study comparing lovastatin 5 mg/day with atorvastatin 80 mg/day was unable to detect any difference in outcomes in patients with stable coronary disease, despite the greater LDL-cholesterol lowering with the atorvastatin, possibly because it was not powered to do so. In a retrospective cohort study, atorvastatin 10 mg/day, pravastatin 20 mg/day, simvastatin 20 mg/day, lovastatin 20 mg/day and fluvastatin 20 mg/day had similar efficacy as secondary prevention after acute myocardial infarction. At present, the evidence from clinical trials is favouring the intensity of the effect on LDL-cholesterol and/or C-reactive protein (CRP) with atorvastatin 80 mg, rather than the use of atorvastatin per se, when greater benefits are observed with the 80 mg dose of atorvastatin compared to other statins. Thus, at present, it is not clear whether atorvastatin is superior to other statins in some indications (coronary heart disease, acute coronary syndromes) or whether it is the intensive lipid lowering that is responsible for the superiority. Atorvastatin has little or no ability to increase high density lipoprotein (HDL)-cholesterol, and this may be a disadvantage in patients with metabolic syndrome or diabetes, where low HDL-cholesterol is a key feature. Thus, other statins should probably be preferred to atorvastatin in patients with diabetes/metabolic syndrome. Alternatively, atorvastatin can be used in combination with a fibrate to increase HDL-cholesterol in patients with diabetes/metabolic syndrome.
安慰剂对照临床试验表明，阿托伐他汀对患有心肌缺血、确诊冠心病、高血压以及其他3种心血管危险因素（如左心室肥厚、2型糖尿病、吸烟）的患者有益，对糖尿病患者也有益，但对钙化性主动脉瓣狭窄患者无效。最近的研究表明，对于患有冠心病和另一种高危因素（既往心肌梗死、冠状动脉血运重建或心绞痛）的患者，每天服用80毫克阿托伐他汀强化降低低密度脂蛋白（LDL）胆固醇比每天服用10毫克阿托伐他汀具有更大的临床益处，并且在急性冠状动脉综合征患者中，其效果优于每天服用40毫克普伐他汀的中度降脂治疗。然而，一项比较每天服用5毫克洛伐他汀和80毫克阿托伐他汀的小型研究未能发现稳定性冠心病患者在治疗结果上有任何差异，尽管阿托伐他汀降低LDL胆固醇的幅度更大，这可能是因为该研究的样本量不足以检测出差异。在一项回顾性队列研究中，每天服用10毫克阿托伐他汀、20毫克普伐他汀、20毫克辛伐他汀、20毫克洛伐他汀和20毫克氟伐他汀在急性心肌梗死后二级预防中的疗效相似。目前，临床试验的证据表明，当每天服用80毫克阿托伐他汀与其他他汀类药物相比能观察到更大益处时，是其对LDL胆固醇和/或C反应蛋白（CRP）的作用强度，而非阿托伐他汀本身的使用，带来了更大益处。因此，目前尚不清楚阿托伐他汀在某些适应症（冠心病、急性冠状动脉综合征）中是否优于其他他汀类药物，或者是强化降脂治疗导致了其优越性。阿托伐他汀升高高密度脂蛋白（HDL）胆固醇的能力很小或几乎没有，这对于代谢综合征或糖尿病患者可能是一个劣势，因为低HDL胆固醇是这些疾病的关键特征。因此，对于糖尿病/代谢综合征患者，可能应优先选择其他他汀类药物而非阿托伐他汀。或者，阿托伐他汀可与贝特类药物联合使用，以提高糖尿病/代谢综合征患者的HDL胆固醇水平。
