A meta-analysis published in the American Journal of Cardiology included 8 prospective randomized trials (1,881 patients) using serial coronary intravascular ultrasound. High-intensity statin therapy attenuated the progression of coronary atherosclerosis in patients with coronary artery disease irrespective of baseline lipid or C-reactive protein levels. The investigators conclude that these results support the latest 2013 American College of Cardiology/American Heart Association guidelines recommending the use of high-intensity statin therapy (to achieve a reduction in low-density lipoprotein cholesterol [LDL-C] of >50%) in high-risk patients, regardless of baseline lipid status.

In contrast to these conclusions, another recent analysis of the Study of Coronary Atheroma by Intravascular Ultrasound: Effect of Rosuvastatin Versus Atorvastatin (SATURN) trial, included in the meta-analysis, by the same group, reported that high-intensity statin therapy induced a regression of coronary atherosclerosis in patients with diabetes mellitus (DM) to a similar degree as that in patients without DM only when on-treatment LDL-C levels were <70 mg/dl (1.8 mmol/L). Percentage atheroma volume reduction was less in patients with DM compared with patients without DM with on-treatment LDL-C levels >70 mg/dl (1.8 mmol/L; p = 0.03), but similar (p = 0.5) when LDL-C levels were ≤70 mg/dl (1.8 mmol/L) ; these results support the adoption of specific LDL-C targets. Besides, other data from the SATURN trial suggest that women with coronary artery disease demonstrate greater coronary atheroma regression than men when prescribed potent statin therapy. Finally, another analysis of SATURN suggests that rosuvastatin produced greater reductions in LDL-C (<70 mg/dl; 1.8 mmol/L) and greater increases in high-density lipoprotein cholesterol than atorvastatin. These changes were directly related with greater reductions of total atheroma volume in older patients, women, patients with DM, and in patients with higher systolic blood pressure, LDL-C, or triglycerides at baseline. The potentially conflicting interpretation of intravascular ultrasound results in relation to lipid levels and targets can confuse readers. It may be that specific lipid targets will better substantiate the need for high-statin intensity or even combinations with other LDL-C lowering drugs (ezetimibe, colesevelam, or new lipid lowering drugs in the pipeline). The aim must be to maximize atheroma regression and stabilization so as to reduce cardiovascular disease risk in different patient populations.