Background

Type 2 diabetes is associated with a substantially increased risk of cardiovascular disease, but the role of lipid-lowering therapy with statins for the primary prevention of cardiovascular disease in diabetes is inadequately defined. We aimed to assess the effectiveness of atorvastatin 10 mg daily for primary prevention of major cardiovascular events in patients with type 2 diabetes without high concentrations of LDL-cholesterol.

Methods

2838 patients aged 40–75 years in 132 centres in the UK and Ireland were randomized to placebo (n=1410) or atorvastatin 10 mg daily (n=1428). Study entrants had no documented previous history of cardiovascular disease, an LDL-cholesterol concentration of 4.14 mmol/L or lower, a fasting triglyceride amount of 6.78 mmol/L or less, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. The primary endpoint was time to first occurrence of the following: acute coronary heart disease events, coronary revascularization, or stroke. Analysis was by intention to treat.

Findings

The trial was terminated 2 years earlier than expected because the prespecified early stopping rule for efficacy had been met. Median duration of follow-up was 3.9 years (IQR 3.0–4.7). 127 patients allocated placebo (2.46 per 100 person-years at risk) and 83 allocated atorvastatin 1.54 per 100 person-years at risk) had at least one major cardiovascular event (rate reduction 37% [95% CI –52 to –17], p=0.001). Treatment would be expected to prevent at least 37 major vascular events per 1000 such people treated for 4 years. Assessed separately, acute coronary heart disease events were reduced by 36% (–55 to –9), coronary revascularisations by 31% (–59 to 16), and rate of stroke by 48% (–69 to –11). Atorvastatin reduced the death rate by 27% (–48 to 1, p=0.059). No excess of adverse events was noted in the atorvastatin group.

Interpretation

Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first cardiovascular disease events, including stroke, in patients with type 2 diabetes without high LDL-cholesterol. No justification is available for having a particular threshold level of LDL-cholesterol as the sole arbiter of which patients with type 2 diabetes should receive statins. The debate about whether all people with this disorder arrant statin treatment should now focus on whether any patients are at sufficiently low risk for this treatment to be withheld.

Lancet

2004;364:685-696.

Helen M. Colhoun, D. John Betteridge, Paul N. Durrington, Graham A. Hitman, H. Andrew W. Neil, Shona J. Livingstone, Margaret J. Thomason, Michael I. Mackness, Valentine Charlton-Menys, John H. Fuller, on behalf of the CARDS investigators