The MRC/BHF Heart Protection Study was one of the landmark trials that have established the place of statins in the management of hypercholesterolaemia. A population of 20,536 patients at high cardiovascular risk through the presence of coronary disease, other arterial disease or diabetes were randomly assigned to treatment with simvastatin or placebo for an average of 5 years.

The intervention was highly effective, with a significant reduction in the risk of cardiovascular events of 24%. However, a majority of cardiovascular risk remains unaffected after statin treatment, and almost 20% of patients in the statin group had a major cardiovascular event during the 5-year follow-up period.

Total cholesterol and LDL-cholesterol were markedly reduced by treatment with the statin (mean changes from baseline of –1.2 mmol/L [–46 mg/dL] and –1.0 mmol/L [–39 mg/dL], respectively). However, other lipid components, such as triglycerides or HDL-cholesterol, impact importantly on cardiovascular risk and were changed only slightly in the study (mean changes from baseline of –0.3 mmol/L [–27 mg/dL] and 0.03 mmol/L [1 mg/dL], respectively).

We may need to look beyond effects on LDL-cholesterol to achieve greater results in the management of overall cardiovascular risk.