Efficacy of statins for primary prevention in people at low cardiovascular risk: a meta-analysis

Background:

Statins were initially used to improve cardiovascular outcomes in people with established coronary artery disease, but recently their use has become more common in people at low cardiovascular risk. We did a systematic review of randomized trials to assess the efficacy and harms of statins in these individuals.

Methods:

We searched MEDLINE and EMBASE (to Jan. 28, 2011), registries of health technology assessments and clinical trials, and reference lists of relevant reviews. We included trials that randomly assigned participants at low cardiovascular risk to receive a statin versus a placebo or no statin. We defined low risk as an observed 10-year risk of less than 20% for cardiovascular-related death or nonfatal myocardial infarction, but we explored other definitions in sensitivity analyses.

Results:

We identified 29 eligible trials involving a total of 80 711 participants. All-cause mortality was significantly lower among patients receiving a statin than among controls (relative risk [RR] 0.90, 95% confidence interval [CI] 0.84–0.97) for trials with a 10-year risk of cardiovascular disease < 20% [primary analysis] and 0.83, 95% CI 0.73–0.94, for trials with 10-year risk < 10% [sensitivity analysis]). Patients in the statin group were also significantly less likely than controls to have nonfatal myocardial infarction (RR 0.64, 95% CI 0.49–0.84) and nonfatal stroke (RR 0.81, 95% CI 0.68–0.96). Neither metaregression nor stratified analyses suggested statistically significant differences in efficacy between high-and low-potency statins, or larger reductions in cholesterol.

Interpretation:

Statins were found to be efficacious in preventing death and cardiovascular morbidity in people at low cardiovascular risk. Reductions in relative risk were similar to those seen in patients with a history of coronary artery disease.Although statins are known to improve survival and relevant clinical outcomes in high-risk populations,¹ evidence of their clinical benefit in lower risk populations is more equivocal. Initially, low-risk populations were defined by the absence of known coronary artery disease (and their treatment was termed “primary prevention”). However, it was subsequently recognized that these populations included both patients at very high risk of coronary artery disease (e.g., those with severe peripheral vascular disease) and those at very low risk (e.g., those aged < 40 years who have no diabetes or hypertension and have low-density lipoprotein cholesterol level of less than 1.8 mmol/L). Accordingly, current guidelines for the use of statins are based on the projected risk of an atherosclerotic event rather than solely on the presence or absence of known coronary artery disease.^2,3Results of the recent JUPITER study (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin)⁴ have renewed enthusiasm for the use of statins in people without a history of coronary artery disease and have generated further controversy as to whether high-potency statins such as rosuvastatin and atorvastatin lead to better clinical outcomes than low-potency statins such as pravastatin, simvastatin, fluvastatin and lovastatin. We did a systematic review of randomized trials to assess the efficacy and harms of statins in people at low cardiovascular risk, including indirect comparisons of high-potency and low-potency statins.     

An assessment of mumps vaccine effectiveness by dose during an outbreak in Canada

Background

This investigation was done to assess vaccine effectiveness of one and two doses of the measles, mumps and rubella (MMR) vaccine during an outbreak of mumps in Ontario. The level of coverage required to reach herd immunity and interrupt community transmission of mumps was also estimated.

Methods

Information on confirmed cases of mumps was retrieved from Ontario’s integrated Public Health Information System. Cases that occurred between Sept. 1, 2009, and June 10, 2010, were included. Selected health units supplied coverage data from the Ontario Immunization Record Information System. Vaccine effectiveness by dose was calculated using the screening method. The basic reproductive number (R₀) represents the average number of new infections per case in a fully susceptile population, and R₀ values of between 4 and 10 were considered for varying levels of vaccine effectiveness.

Results

A total of 134 confirmed cases of mumps were identified. Information on receipt of MMR vaccine was available for 114 (85.1%) cases, of whom 63 (55.3%) reported having received only one dose of vaccine; 32 (28.1%) reported having received two doses. Vaccine effectiveness of one dose of the MMR vaccine ranged from 49.2% to 81.6%, whereas vaccine effectiveness of two doses ranged from 66.3% to 88.0%. If we assume vaccine effectiveness of 85% for two doses of the vaccine, vaccine coverage of 88.2% and 98.0% would be needed to interrupt community transmission of mumps if the corresponding reproductive values were four and six.

Interpretation

Our estimates of vaccine effectiveness of one and two doses of mumps-containing vaccine were consistent with the estimates that have been reported in other outbreaks. Outbreaks occurring in Ontario and elsewhere serve as a warning against complacency over vaccination programs.Between September 2009 and June 2010, there was an outbreak of mumps in Ontario, Canada. Outbreaks of mumps were also taking place in the United States (New York and New Jersey) and in Israel during the same period.^1,2 These outbreaks shared several features, including the age distribution of the cases, the predominance of male cases and the occurrence of the disease among people who had received vaccinations against mumps.^1,2 This latter issue can lead to questions from the public and health care providers regarding the effectiveness of the vaccine. Rapid assessment of vaccine effectiveness is, therefore, an important component of outbreak management for vaccine-preventable diseases, and knowledge of the history of the vaccination program is necessary for interpreting the results.A live attenuated mumps vaccine was licensed in Canada in 1969 and introduced in Ontario shortly thereafter. In 1975, a single dose of the combined vaccine for measles, mumps and rubella (MMR) was implemented. A single-dose program continued until 1996, when a second dose of the MMR vaccine was introduced as part of a plan to eradicate measles. The first dose of the MMR vaccine is routinely given at 12 months of age; until 2007, the second dose was recommended for children between four and six years of age. The recommended age for the second dose is now 18 months.Two MMR vaccines are available for use in Ontario. A single dose of monovalent measles vaccine was offered to all students aged 4–18 years in 1996 as part of a measles catch-up campaign. Because mumps-containing vaccine was not used, a cohort of individuals born before 1992 who had only received one dose of mumps-containing vaccine were therefore potentially susceptible to the virus.Epidemiologic data show that the mumps virus circulated relatively widely throughout Ontario until approximately 1980 (M.A. Simpson, Ontario Ministry of Health and Long-Term Care, Toronto, Ont.: personal communication, 2011 Feb. 1), which would have resulted in the natural boosting of the population’s immunity to the disease. The combination of changes in the policy governing vaccination against mumps and the circulation of the disease thus resulted in a susceptible cohort of individuals born between approximately 1980 and 1992 (i.e., people currently between 19 and 31 years of age).A person’s susceptibility to mumps is also influenced by the effectiveness of the vaccine he or she received. Clinical trials have reported vaccine efficacy of approximately 95% after one dose of mumps vaccine under controlled conditions, although estimates of vaccine effectiveness that were conducted in the field (as opposed to clinical trials) have been much lower (i.e., 62%–85%).³ There is less information available about vaccine effectiveness after two doses, but estimates have ranged from 76% to 95%,^3–5 with accumulating evidence of waning immunity.^2–6The objectives of this investigation were to assess the vaccine effectiveness of MMR vaccine by dose and by birth cohort during the outbreak, and to estimate the level of vaccine coverage required to reach herd immunity and interrupt community transmission of mumps.     

Cost-effectiveness of the use of low- and high-potency statins in people at low cardiovascular risk

Background:

Although statins have been shown to reduce the risk of cardiovascular events in patients at low cardiovascular risk, their absolute benefit is small in the short term, which may adversely affect cost-effectiveness. We sought to determine the long-term cost-effectiveness (beyond the duration of clinical trials) of low- and high-potency statins in patients at low cardiovascular risk and to estimate the impact on Canada’s publicly funded health care system.

Methods:

Using Markov modelling, we performed a cost-utility analysis in which we compared low-potency statins (fluvastatin, lovastatin, pravastatin and simvastatin) and high-potency statins (atorvastatin and rosuvastatin) with no statins in a simulated cohort of low-risk patients over a lifetime horizon. Model outcomes included costs (in 2010 Canadian dollars), quality-adjusted life-years (QALYs) gained and the cost per QALY gained.

Results:

Over a lifetime horizon, the cost of managing a patient at low cardiovascular risk was estimated to be about $10 100 without statins, $15 200 with low-potency statins and $16 400 with high-potency statins. The cost per QALY gained with high-potency statins (v. no statins) was $21 300; the use of low-potency statins was not considered economically attractive. These results were robust to sensitivity analyses, although their use became economically unattractive when the duration of benefit from statin use was assumed to be less than 10 years.

Interpretation:

Use of high-potency statins in patients at low cardiovascular risk was associated with a cost per QALY gained that was economically attractive by current standards, assuming that the benefit from statin use would continue for at least 10 years. However, the overall expenditure on statins would be substantial, and the ramifications of this practice should be carefully considered by policy-makers.Although statins improve survival and reduce the risk of cardiovascular events in populations at high and moderate risk,¹ their effectiveness and cost-effectiveness in low-risk populations is less certain.² This uncertainly is due in part to low-risk patients being less likely to have cardiovascular events over the short term. For instance, in the recent Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study³ — a large randomized trial comparing cardiovascular outcomes in low-risk patients randomly assigned to receive either rosuvastatin or placebo — the risk of death or nonfatal myocardial infarction over three years was 2.5% in the rosuvastatin group and 3.5% in the placebo group, which represented a large relative, but small absolute, risk reduction in cardiovascular events.Other cholesterol-lowering interventions are available, such as diet, exercise and the use of other hypolipidemic agents, but the use of statins is the only such intervention known to reduce cardiovascular risk in people with low and high blood cholesterol levels.^4–7 Thus, statins are now primarily indicated for the reduction of cardiovascular risk instead of being used mainly for the management of hypercholesterolemia.⁸With this broadening indication for use, expenditures on statins have increased and represent about 13% of total expenditures by provincial formularies in Canada.⁹ The absolute number of people at low cardiovascular risk who are taking statins has increased substantially over the last decade, driven by the large number of low-risk people in the general population.¹⁰ In addition, statins that are more effective in lowering low-density lipoprotein (LDL) cholesterol levels have become available.^3,11 These high-potency statins (atorvastatin and rosuvastatin) are substantially more expensive than low-potency statins available as generics (pravastatin, simvastatin, fluvastatin and lovastatin), although atorvastatin has recently become available as a generic in Canada.¹² Increasing costs and concerns over the absolute benefit of statins in people at low cardiovascular risk has raised concerns about the cost-effectiveness of statins in this group.We performed an incremental cost-utility analysis comparing low- and high-potency statins with no statins in patients at low cardiovascular risk in a Canadian setting. We used findings from our group’s recent systematic review of the efficacy of statins for primary prevention in low-risk people¹³ as well as observational data from a large provincial registry of patients documenting existing statin use. Our objective was to determine which strategy represents the best use of health care resources for the publicly funded health care system, and what investment would be required to fund statins.     

High level expression of a recombinant xylanase by Pichia pastoris NC38 in a 5 L fermenter and its efficiency in biobleaching of bagasse pulp

A genetically modified XynA gene from Thermomyces lanuginosus was expressed in Pichia pastoris under the control of GAP promoter. P. pastoris expressed greater levels of xylanase (160 IU ml(-1)) on BMGY medium without zeocin after 56 h. The xylanase production by recombinant P. pastoris was scaled up in a 5L fermenter containing 1% glycerol and the highest xylanase production of 139 IU ml(-1) was observed after 72 h. Further studies carried out in fermenter under controlled pH (5.5) yielded a maximum xylanase production of 177 IU ml(-1) after 72 h. The biobleaching efficacy of crude xylanase was also evaluated on bagasse pulp and a brightness of 47.4% was observed with 50 IU of crude xylanase used per gram of pulp, which was 2.1 points higher in brightness than the untreated samples. Reducing sugars (24.8 mg g(-1)) and UV absorbing lignin-derived compounds values were considerably higher with xylanase treated samples.     

Potent and selective thiophene urea-templated inhibitors of S6K

S6K1 (p70 S6 kinase-1) is thought to play a critical role in the development of obesity and insulin resistance, thus making it an attractive target in developing medicines for the treatment of these disorders. We describe a novel thiophene urea class of S6K inhibitors. The lead matter for the development of these inhibitors came from mining the literature for reports of weak off-target S6K activity. These optimized inhibitors exhibit good potency and excellent selectivity for S6K over a panel of 43 kinases.     

Influenza 2009 pandemic: Cellular immunemediated surveillance modulated by TH17 & Tregs

Influenza A virus is a serious public health threat. Most recently the 2009/H1N1 pandemic virus had an inherent ability to evade the host's immune surveillance through genetic drift, shift, and genomic reassortment. Immune characterization of 2009/H1N1 utilized monoclonal antibodies, neutralizing sera, and proteomics. Increased age may have provided some degree of immunity, but vaccines against seasonal influenza viruses seldom yield cross-reactive immunity, exemplified by 2009/H1N1. Nonetheless, about 33% of individuals, over the age of 60, had cross-reactive neutralizing antibodies against 2009/H1N1, whereas only 6-9% young adults had these antibodies. Children characteristically had no detectable immunity against 2009/H1N1. Taken together, these observations suggest some degree of immune transference with at least certain strains of virus that have afflicted the human population in past decades. Because internal influenza proteins may exhibit less antigenic variation, it is possible that prior exposure to diverse strains of influenza virus provide some immunity to novel strains, including the recent pandemic strain (swine-avian A/H1N1). Current trends in immunological studies - specifically the modulation of cellular immune surveillance provided by TH17 and Tregs - also support the need for additional proteomic research for characterizing novel translational evidence-based treatment interventions based on cytokine function to help defeat the virus. Timely and critical research must characterize the impact of genetics and epigenetics of oral and systemic host immune surveillance responses to influenza A virus. The continued development and application of proteomics and gene expression across viral strains and human tissues increases our ability to combat the spread of influenza epidemics and pandemics.     

Effects of gradual-elastic compression stockings on running economy, kinematics, and performance in runners

We investigated the effect of gradual-elastic compression stockings (GCSs) on running economy (RE), kinematics, and performance in endurance runners. Sixteen endurance trained athletes (age: 34.73 ± 6.27 years; VO2max: 62.83 ± 9.03 ml·kg(-1)·min(-1); 38 minutes in 10 km; 1 hour 24 minutes in half marathon) performed in random order 4 bouts of 6 minutes at a recent half-marathon pace on a treadmill to evaluate RE with or without GCSs. Subsequently, 12 athletes were divided into 2 equal groups matched by their VO2max, and they performed a time limit test (T(lim)) on a treadmill at 105% of a recent 10-km pace with or without GCSs for evaluation of physiological responses and running kinematics. There were no significant differences in the RE test in all of the variables analyzed for the conditions, but a moderate reproducibility for some physiological responses was detected in the condition with GCSs. In the T(lim), the group that wore GCSs reached a lower % of maximum heart rate (HRmax) compared with the control group (96.00 ± 2.94 vs. 99.83 ± 0.40) (p = 0.01). Kinematics did not differ between conditions during the T(lim) (p > 0.05). There were improvement trends for time to fatigue (337 vs. 387 seconds; d = 0.32) and a lower VO2peak (≈53 vs. 62 ml·kg(-1)·min(-1); d = 1.19) that were detected with GCSs during the T(lim). These results indicate that GCSs reduce the % of HRmax reached during a test at competition pace. The lower reproducibility of the condition with GCSs perhaps suggests that athletes may possibly need an accommodation period for systematically experiencing the benefits of this garment, but this hypothesis should be further investigated.     

Essential oils of Cupressus funebris, Juniperus communis, and J. chinensis (Cupressaceae) as repellents against ticks (Acari: Ixodidae) and mosquitoes (Diptera: Culicidae) and as toxicants against mosquitoes

Juniperus communis leaf oil, J. chinensis wood oil, and Cupressus funebris wood oil (Cupressaceae) from China were analyzed by gas chromatography and gas chromatography-mass spectrometry. We identified 104 compounds, representing 66.8-95.5% of the oils. The major components were: α-pinene (27.0%), α-terpinene (14.0%), and linalool (10.9%) for J. communis; cuparene (11.3%) and δ-cadinene (7.8%) for J. chinensis; and α-cedrene (16.9%), cedrol (7.6%), and β-cedrene (5.7%) for C. funebris. The essential oils of C. funebris, J. chinensis, and J. communis were evaluated for repellency against adult yellow fever mosquitoes, Aedes aegypti (L.), host-seeking nymphs of the lone star tick, Amblyomma americanum (L.), and the blacklegged tick, Ixodes scapularis Say, and for toxicity against Ae. aegypti larvae and adults, all in laboratory bioassays. All the oils were repellent to both species of ticks. The EC(95) values of C. funebris, J. communis, and J. chinensis against A. americanum were 0.426, 0.508, and 0.917 mg oil/cm(2) filter paper, respectively, compared to 0.683 mg deet/cm(2) filter paper. All I. scapularis nymphs were repelled by 0.103 mg oil/cm(2) filter paper of C. funebris oil. At 4 h after application, 0.827 mg oil/cm(2) filter paper, C. funebris and J. chinensis oils repelled ≥80% of A. americanum nymphs. The oils of C. funebris and J. chinensis did not prevent female Ae. aegypti from biting at the highest dosage tested (1.500 mg/cm(2) ). However, the oil of J. communis had a Minimum Effective Dosage (estimate of ED(99) ) for repellency of 0.029 ± 0.018 mg/cm(2) ; this oil was nearly as potent as deet. The oil of J. chinensis showed a mild ability to kill Ae. aegypti larvae, at 80 and 100% at 125 and 250 ppm, respectively.