The cholesterol paradox in heart failure.

Heart failure (HF) is a common and serious condition that is usually due to coronary artery disease (CAD). Hypercholesterolemia is a major risk factor for CAD but, paradoxically, patients with advanced HF often have low cholesterol, which is associated with a poor prognosis. Cholesterol lowering with statins reduces morbidity and mortality in patients with CAD who do not have HF and might also have improved outcome in patients with HF had they not been excluded from the reported trials. The results of large trials such as the Controlled Rosuvastatin Multinational Study in Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Insufficienza Cardiaca (GISSI-HF) study addressing the effects of rosuvastatin in HF are keenly awaited. In addition to cholesterol lowering, statins have other biologic effects that might be responsible for some of their favorable effects. This article examines this cholesterol paradox and possible mechanisms.

The effects of initiation or continuation of statin therapy on cholesterol level and all-cause mortality after the diagnosis of left ventricular systolic dysfunction.

BACKGROUND: Statins (3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors) are known to reduce mortality and cardiac events in patients with coronary artery disease who have not progressed to left ventricular systolic dysfunction (LVSD) and/or heart failure (HF). This study investigated the effect of changes in statin therapy and cholesterol level on mortality in patients with LVSD. METHODS: Data from consecutive patients with LVSD enrolled in a single local hospital HF management program were analyzed. Patients were grouped according to changes in statin treatment within 4 months after their initial visit: groups NS (no statin), IS (initiation of statin), CS (continuation of statin), and SS (statin stopped). RESULTS: Nine hundred patients were followed for a median of 36 (28-43) months (range, 16-66 months). The 2-year mortality was 16.7%. Groups IS and CS had lower 2-year mortality than groups NS and SS (11.0% and 11.9% vs 22.0% and 34.8%, respectively; P < .001). This was independent of age, sex, severity of LVSD, HF medications, New York Heart Association functional class, and baseline cholesterol. The effect was mainly observed in patients with coronary artery disease. In 734 patients who had completed 1-year follow-up on stable HF treatment, neither baseline cholesterol nor change over 1 year predicted outcome. CONCLUSION: Initiation and maintenance of treatment with statins is associated with better survival in patients with LVSD. This could not be explained by other measured variables.