Simopoulos AP, De Meester F (eds): A Balanced Omega-6/ Omega-3 Fatty Acid Ratio, Cholesterol and Coronary

Heart Disease. World Rev Nutr Diet. Basel, Karger, 2009, vol 100, pp 8089

Disappointing Recent Cholesterol-Lowering

Drug Trials: Is It Not Time for a Full
Reappraisal of the Cholesterol Theory?
Michel de Lorgeril
Cur et Nutrition, Universit Joseph Fourier-Grenoble 1, CNRS, Laboratoire TIMC-IMAG, UMR 5525,
Facult de Mdecine, Grenoble, France

Recent cholesterol-lowering drug trials have been very disappointing for cholesterol experts and the cholesterol drug industry. Three events as important in terms
of media coverage as of science and medicine are held each year around the issue of
cholesterol: the annual meeting of the American College of Cardiology in March, the
annual meeting of the European Society of Cardiology in August, and the American
Heart Association meeting in November. Because thousands of cardiologists from all
continents are at the same place at the same time, each of these meetings is an opportunity to roll out cholesterol drug marketing campaigns. Today, marketing is primarily based on the publication of results of randomized trials. Thus every year, the three
cardiology world meetings are the best time to re-launch the cholesterol-lowering
drug machine. However, the year 2008 has been a sad year because trial results obviously do not support the theory according to which cholesterol lowering results have
significant benefits in the prevention of coronary heart disease (CHD), including the
so-called the lower the better theory.

The ENHANCE Study

The results of the ENHANCE study conducted in patients with familial hypercholesterolemia [1] were published in March 2008 and were disappointing. Familial
hypercholesterolemia is supposed to be a typical cholesterol-driven disease with dramatically high LDL cholesterol levels resulting in CHD complications. In ENHANCE,
an association of ezetimibe, a drug acting by decreasing the absorption of cholesterol
in the digestive tract, and simvastatin, which acts by decreasing the endogenous synthesis of cholesterol, was tested. For those who believe that cholesterol is the main

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cause of CHD, ENHANCE was designed not to fail. Actually, the association of the
two drugs in the same patient resulted in a drastic reduction of cholesterol levels, in
particular LDL cholesterol (the so-called bad cholesterol) levels. Since ezetimibe is
not absorbed in the digestive tract and simvastatin given at a relatively low dose, the
rate of side effects in ENHANCE was expected to be low. Thus, contamination of the
potential effectiveness measurement of the treatment by side effects also was expected
to be low. The test was not performed by measuring hard clinical endpoints such
as cardiac death or myocardial infarction, but by repeated measurements of carotid
intima-media thickness (IMT), a supposed marker of atherosclerosis progress.
Unexpectedly, the combination of the two drugs failed to provide incremental benefits over simvastatin alone, despite a drastic reduction in cholesterol [1]. In addition,
both treatments did not result in significant effects on the primary endpoints: not
only did the change in IMT not differ over time, from baseline to 24 months, between
the two study groups, but there was a slight increase in IMT in both groups: at 2 years,
the estimates were of +0.0095 0.0040 mm in the simvastatin only group (p = 0.02 vs.
baseline) and +0.0121 0.0038 mm in the combined therapy group (p < 0.01 vs. baseline), which suggested that unexpectedly the lower the cholesterol, the greater was
the increase in IMT [1]. These surprising and very disappointing data might explain
why the results of ENHANCE were hidden from the medical community for nearly
2 years, while the drug was being used by millions of patients over the world, hoping
that it was protecting their hearts [25].
It is noteworthy that until ENHANCE, IMT was used as a surrogate of CHD complications [6, 7]. This was supported by several studies showing that intensive cholesterol lowering inevitably resulted in IMT regression [8, 9]. If ENHANCE had been
positive, IMT would have been celebrated again as an effective marker of the risk of
CHD complication. Because ENHANCE was negative, cholesterol experts immediately claimed that IMT cannot be a marker of atherosclerosis progress or a surrogate of CHD [10, 11]. More surprisingly, after ENHANCE many cholesterol experts
declared that familial hypercholesterolemia is not the adequate population to test the
effects of cholesterol lowering [25]. Instead, a scientist would have concluded that
if this potent association of drugs does not work in familial hypercholesterolemia, it
can hardly be expected to work in any other case. Hence, ENHANCE was, by itself, a
cause of confusion and debate among cholesterol experts. The data of ENHANCE led
an American College of Cardiology panel to urge physicians to only prescribe cholesterol-lowering medications with proven clinical effectiveness, i.e. proven effects on
hard clinical CHD endpoints such as cardiac death, myocardial infarction and stroke
[4]. As a matter of fact, ezetimibe was approved and marketed in 2002 based solely
upon a 20% reduction of cholesterol, but not on data related to its effectiveness on any
clinical endpoint [12], as if cholesterol levels by themselves could be a surrogate of
CHD. In addition, the effectiveness of the ezetimibe+simvastatin combination against
hard clinical endpoints has never been demonstrated, as discussed below about the
Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial. As a consequence, many

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physicians and scientists rightly questioned why the combination tablet already was
on the market if there was no proven effect on clinical CHD complications [4, 5].
In March 2008, a press release announced the premature termination of JUPITER,
a trial testing rosuvastatin, presumably the most effective statin in terms of cholesterol lowering, against a placebo in the primary prevention of CHD [13, 14]. With
this announcement, investigators probably wanted to communicate that rosuvastatin, contrary to ezetimibe+simvastatin, resulted in an unequivocal evidence of reduction in cardiovascular morbidity and mortality as written in the press release [13, 14].
This was quite strategic for cholesterol experts at that particular time, because several
trials testing cholesterol-lowering had been published during the previous years in
various clinical circumstances, ASPEN, 4D, PREVENT IT, IDEAL, ILLUMINATE
[1519] and also ENHANCE [1], and all of them reported no convincing protective
effect against CHD complications [1, 1519]. The failure of ENHANCE, in particular,
generated unprecedented media coverage, patient and physician concerns, and the
involvement of the US Congress over the use of cholesterol-lowering drugs to reduce
CHD risk [25, 10, 11]. The controversy even brought into question the role of blood
cholesterol as a proven surrogate of atherosclerosis [11].
Following the publication of ENHANCE, two studies of cholesterol-lowering
treatments following protocols approved by the FDA were either not published or
abruptly terminated [20, 21]. CASHMERE tested atorvastatin in postmenopausal
women. The trial results were unearthed by capital market analyst Robert Hazlett
and showed no effect at all on IMT [20]. ACHIEVE tested a novel combination tablet associating niacin and laropiprant (a prostaglandin D blocker used to prevent
the flushing induced by niacin) in familial hypercholesterolemia [21]. The trial was
prematurely stopped because, after the failure of ENHANCE in the same category
of patients, sponsors and investigators thought that there was no hope to demonstrate a benefit [21]. This indicated that even in 2008, trials that were obviously
negative or tended in the wrong direction were still not publicly discussed by investigators and sponsors and sometimes were halted before completion. This gives an
idea of what was being done before the new clinical research regulation came into
force in 20052006, after the Vioxx affair [22], with the obligation of declaring all
the clinical trials and of publishing the results even when they are not favorable to
the tested drug [23, 24]. All these attempts to mislead the medical and scientific
community have highlighted the fact that the alleged effectiveness of cholesterol
lowering to prevent CHD complications is very questionable for anyone wanting to
open their eyes.
2

SEAS and GISSI-HF

The results of two important trials were reported in 2008: SEAS and GISSI-HF [25,
26].

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The SEAS trial was a randomized, placebo-controlled study evaluating

ezetimibe+simvastatin, like ENHANCE [1]. This time, however, cholesterol lowering was tested against a placebo by evaluating its effects on hard clinical endpoints,
including aortic valve replacement and CHD complications in patients with aortic
stenosis [25]. The main assumption was that disease progression in aortic stenosis is
strongly influenced by hypercholesterolemia [27, 28] and often associated with CHD
complications [29, 30]. Thus, double benefits were expected in these patients: first, by
preventing CHD complication and second, by preventing aortic valve complications.
The primary endpoint of the trial was therefore a combination of CHD and aortic
valve complications.
To summarize SEAS results, drastic cholesterol lowering had no significant effect
on the primary endpoint [25]. While the authors tried to present the SEAS data in
a positive light by claiming that cholesterol lowering had a significant effect on secondary endpoints such as coronary revascularization, SEAS actually confirmed the
negative results of ENHANCE, but this time for hard clinical endpoints [25]. From a
scientific point of view, SEAS is a critical study for several reasons.
First, SEAS confirmed previous recent trials [1519], including ENHANCE [1], and
the inability of cholesterol lowering to reduce the risk of CHD complications in certain
populations. This raised the question of whether the failure of ezetimibe+simvastatin
was due to some unknown side effects of the combined treatment or to the fact that
cholesterol lowering actually is beneficial in certain populations of patients and not
in others. In fact, some experts have claimed that previous positive trials were not the
result of cholesterol lowering but of other properties of statins, the so-called pleiotropic effects of statins [31]. At this point in the controversy, cholesterol experts appeared
to be divided into two groups: those who were claiming that cholesterol lowering is
still important whatever the results of ENHANCE and SEAS, and those claiming that
cholesterol lowering is not important as long as patients receive intensive statin treatment in order to induce pleiotropic protection [25, 32].
Second, the control group in SEAS received a placebo, whereas in ENHANCE the
comparison group received simvastatin alone. This means that the difference in LDL
cholesterol between the experimental and the control group was huge in SEAS, close
to 50%, but still did not provide any protection. Thus, ENHANCE and SEAS taken
together should have logically led to reject the the lower the better theory that states
that the lower the cholesterol, the better the protection [33, 34].
Third, it is noteworthy that in SEAS, patients with low cholesterol levels in the
experimental group had more cancers and died more frequently from cancers than
those receiving the placebo [25]. Although it can be speculated that the increased
cancer rate was a chance effect [35, 36], this raises another critical question: may
intensive cholesterol lowering increase the risk of cancers in certain patients?
No one can answer that question today. Given the millions of patients receiving
intensive cholesterol-lowering treatment without any unambiguous cardiovascular
benefits, the next critical question is whether we should not follow precautionary

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principles on this public health issue and at least fully inform the public about these
questions.
GISSI-HF was a double-blind randomized trial testing whether 10 mg rosuvastatin compared with a placebo could reduce mortality and cardiac complications
in patients with chronic heart failure (CHF) from various causes [26]. Large observational studies, small prospective studies and post-hoc analyses (including metaanalyses) of large randomized trials have indeed suggested that cholesterol-lowering
could be beneficial in CHF patients. Despite a 36% reduction of LDL cholesterol in
the statin group compared with placebo, there was no difference between groups for
total mortality (657 deaths versus 644 in the placebo group) and for other cardiovascular endpoints in GISSI-HF [26].
GISSI-HF thus confirmed the results of a previous trial published less than 1 year
before, the CORONA trial [37]. In CORONA, 10 mg rosuvastatin also were tested
against placebo in patients with CHF aged 60 years and more. Contrary to GISSI-HF,
all patients in CORONA were CHD patients who had survived a previous myocardial
infarction and presented left ventricular dysfunction. In other words, CORONA was
a secondary prevention trial in high-risk patients because left ventricular dysfunction significantly increases the risk of CHD complications and cardiac death. Before
CORONA, statin experts claimed that the higher the risk of cardiac death was, the
higher the benefits of intensive cholesterol lowering would be [38, 39]. Official and
international guidelines state that a statin should be given to all patients (whatever their
cholesterol level) in high-risk secondary prevention, whereas in primary prevention,
when the risk of cardiac death is lower, prescription should depend on the cholesterol
level [34, 40, 41]. In CORONA, the primary composite outcome was cardiac death,
nonfatal infarction and nonfatal stroke [37]. LDL cholesterol was reduced by 45% and
CRP (an inflammatory marker) by 37% in the rosuvastatin group compared with placebo. CORONA was therefore designed not to fail. However, no significant difference
was recorded for the primary composite outcome. Moreover, there were 488 and 487
cardiovascular deaths in the rosuvastatin and placebo groups, respectively. The numbers of deaths due to worsening heart failure were 191 and 193 in the placebo and
statin groups, respectively. Thus, the unequivocal lessons of CORONA were that both
drastic cholesterol lowering and the supposed pleiotropic (anti-inflammatory) effect
of the statin had no effect at all in the secondary prevention of CHD in high-risk
patients. CORONA and GISSI-HF therefore provided exactly the same information
in two different populations, namely that cholesterol lowering does not improve the
prognosis for high-risk CHD patients. The theory that the higher the risk (notably in
secondary prevention of CHD), the higher the benefit [34, 3841] should logically be
rejected. Also, the theory according to which statin pleiotropy could have a significant clinical impact appears to be very elusive after GISSI-HF and CORONA.
Both GISSI-HF and CORONA raise many questions. The main one, however,
is why the most recent statin trials conducted in secondary prevention and highrisk patients, including the patients with familial hypercholesterolemia recruited in

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ENHANCE and those with aortic valve disease recruited in SEAS, have been negative.
An alternative question is whether there were some technical problems and potential
biases in these 4 trials that could have explained the failure. If not, the same question
should be raised about the previous trials reporting high protection with statins, in
particular those conducted during the 1990s, before the Vioxx affair and the new
clinical research regulations [22]. How can we explain the discrepancy between these
older positive trials on one hand, and CORONA, GISSI-HF, ENHANCE and SEAS,
on the other?
Lastly, are the methods and results of previous trials reporting high benefits of
cholesterol lowering verifiable today? Did the new regulations introduced after the
Vioxx affair result in such a striking improvement of trial conduct that all trials are
now negative?

The JUPITER Trial

JUPITER tested the effects of 20 mg rosuvastatin in subjects without cardiovascular

disease, normal cholesterol levels but relatively high CRP [42]. The authors reported
a 50% decrease in LDL cholesterol, a 37% decrease in CRP and a decrease by about
50% in cardiovascular complications. However, there are methodological problems
and major clinical inconsistencies in JUPITER. The main methodological problem in
JUPITER regards the premature trial termination [42]. Investigators made the awkward decision to stop the trial after 393 cases of complications, before the number
of at least 520 events calculated in their analysis plan was reached [42]. Taking only
the hard complications of fatal and nonfatal myocardial infarction and stroke into
account, they actually stopped the trial after only 240 events! The ethical argument
according to which patients in the placebo group could no longer be left untreated is
not relevant, and even the opposite, as many scientific articles constantly stress [43,
44]. Scientific rigueur is the primary ethical rule that has to be followed in clinical
research. Ethics required that the trial should not have been discontinued prematurely, as evidenced by the inconsistency of clinical results (see below).
The results of JUPITER are reproduced in the table 1. They look dramatic. The
primary endpoint is a mix of diverse complications listed in the bottom lines of the
table, although some of them such as revascularization are irrelevant because they
are not complications but medical decisions. This being said, we actually observe an
impressive difference between the two groups in terms of hard clinical complications,
myocardial infarction and stroke (157 against 83). However, there are no clear data on
cardiovascular mortality in the table 1 as well as the text of the article. One may infer
from the table (although this is not indicated in the text) that fatal myocardial infarction is the difference between any myocardial infarction and nonfatal myocardial
infarction, giving total numbers of 9 (31 less 22) in the rosuvastatin group and 6 (68
less 62) in the placebo group. We can make the same calculation for fatal stroke (the

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Table 1. Reproduction of table 3 from the JUPITER paper [42]

Endpoint

Rosuvastatin
(n = 8,901)

Placebo
(n = 8,901)

Primary endpoint
Nonfatal myocardial infarction
Any myocardial infarction
Nonfatal stroke
Any stroke
Arterial revascularization
Hospitalization for unstable angina
Myocardial infarction, stroke, or confirmed deaths from
cardiovascular causes
Death from any cause on known date

142
22
31
30
33
71
16
83

251
62
68
58
64
131
27
157

190

235

difference between any stroke and nonfatal stroke), resulting in total numbers of 3
(33 less 30) in the rosuvastatin group and 6 (64 less 58) in the placebo group.
Cardiovascular mortality (fatal stroke + fatal myocardial infarction) is therefore
identical in the two groups (12 against 12).
The lack of effect on cardiovascular mortality associated with a miraculous effect
on nonfatal complications is puzzling and should have led to suspect a bias and to the
continuation of the trial instead of a premature ending. In addition, the numbers of
fatal myocardial infarction in both groups (9 and 6) are unexpectedly low compared
with nonfatal infarction (62 and 22), suggesting that JUPITER patients, particularly
in the placebo group, withstood the consequences of myocardial ischemia and infarction extremely well. This is apparent even within the first hour following the first
symptoms of chest pain (the definition of sudden cardiac death), since curiously no
sudden cardiac death is reported in the trial. Almost no non-sudden cardiac deaths
are reported either during in the following hours, days and weeks.
We are clearly facing a major clinical inconsistency.
Mortality from myocardial infarction is known to be very high. In fact, the case
fatality rate in epidemiological reports has been reported in many populations with
very different risks [45]. Out of 100 patients who have a myocardial infarction, an
average of 50 die immediately or within the 34 weeks that follow, and almost never
less than 40 out of 100 even in populations with low cardiovascular mortality [45].
In JUPITER, mortality during infarction (6 divided by 68 multiplied by 100) is 8.8%
in the placebo group. This is extremely low, and here we have another major clinical
inconsistency! But does the error lie? Which are the false figures? The case fatality
rate in the rosuvastatin group (9 divided by 22 multiplied by 100) is 29%, a figure that
fits better (although not perfectly) with the expected variations but raises another
question: would rosuvastatin have tripled myocardial infarction-related mortality?

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Is this clinically consistent? Another way to measure the trials clinical consistency
is to compare cardiovascular and total mortality. In most countries, cardiovascular
mortality represents 4560% of total mortality, rarely less than 35%. Yet in JUPITER,
it represents only 6% of total mortality (12 divided by 190 100; table 1) in the statin
group and 5% (12 divided by 235 100) in the placebo group. How incredibly low!
This is another major epidemiological inconsistency.
Pending confirmation of JUPITER by a new trial that will hopefully follow traditional and validated clinical trial methods, the obvious conclusion is that JUPITER
results are not clinically consistent and therefore not credible. We must bear in mind
that two previous trials with rosuvastatin (CORONA and GISSI-HF) were negative
for CHD prevention [26, 37]. Thus, no clinical trial so far has been published showing an unequivocal clinical benefit of rosuvastatin. And this right at the time where
other anticholesterol drugs (tested in ENHANCE and SEAS) were shown to be totally
ineffective whatever the type of hard or surrogate endpoints used to test the effects of
cholesterol lowering [1, 25].

Conclusion

For cholesterol experts and the cholesterol industry, recent cholesterol-lowering drug
trials have definitely been very disappointing. The most recent trials were either
negative (ENHANCE, SEAS, GISSI-HF, CORONA) or not clinically consistent and
probably biased (JUPITER) because of premature termination. Taken together, in
the light of other negative trials (ASPEN, 4D, PREVEND IT, IDEAL, ILLUMINATE)
published after the Vioxx affair in 2005 and the following new clinical research regulations, these trials are puzzling. They suggest that the positive trials published before
2005 and the Vioxx affair should be urgently re-examined. At a minimum, experts
independent of industry and free of conflict of interest should be asked to carefully
check all the raw data recorded in the datasets and redo the statistical analyses.
The next question would then be: is it not time for a full reappraisal of the cholesterol theory?

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Michel de Lorgeril, MD
Cur et Nutrition, Facult de Mdecine, Domaine de la Merci
FR38706 La Tronche (France)
Tel. +33 , Fax +33 , E-Mail michel.delorgeril@ujf-grenoble.fr

Disappointing Recent Cholesterol-Lowering Drug Trials

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