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Race, Ethnicity, and the Efficacy of Rosuvastatin in Primary Prevention: The Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) Trial
Study Questions:
Is there a differential effect of statin treatment for primary prevention of cardiovascular events by race/ethnic groups?
Methods:
The effect of race/ethnic group was assessed in the JUPITER trial, a randomized, double-blind, placebo-controlled evaluation of rosuvastatin 20 mg in the primary prevention of myocardial infarction (MI), stroke, arterial revascularization, hospitalization for unstable angina, and cardiovascular deaths. JUPITER included 12,683 whites and 5,117 nonwhites (self-reported 2,224 black, 2,261 Hispanic, 632 Asian) with low-density lipoprotein (LDL) cholesterol levels <130 mg/dl and high-sensitivity C-reactive protein (hs-CRP) levels ≥2.0 mg/L. The study was stopped with a median duration of 1.9 years, with maximal follow-up of 5 years.
Results:
There was no difference at baseline for the following: median age 66 years, body mass index, or history of hypertension. Nonwhites were more often females, current smokers, lower blood pressures, more likely to have the metabolic syndrome, and higher hs-CRP and triglycerides, but lower total, LDL, and high-density lipoprotein (HDL) cholesterol. In nonwhites, rosuvastatin resulted in lower relative reductions in hs-CRP, LDL cholesterol and apo B, and less increase in hs-CRP. Random allocation to rosuvastatin resulted in a 45% reduction in the primary endpoint among whites (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.43-0.69) and a 37% reduction among nonwhites (HR, 0.63; 95% CI, 0.41-0.99). Blacks (HR, 0.65; 95% CI, 0.35-1.22) and Hispanics (HR, 0.58; 95% CI, 0.25-1.39) had similar risk reductions. Among nonwhites in the placebo group, the stroke rate exceeded the MI rate (0.44 vs. 0.20 per 100 person-years); an opposite pattern was observed among whites (0.31 vs. 0.42 per 100 person-years). Nonwhites had higher death rates than whites (2.25 vs. 0.93 per 100 person-years); however, all-cause mortality was similar at 20% with rosuvastatin treatment in both participant groups.
Conclusions:
When used in primary prevention among individuals with LDL <130 mg/dl and hs-CRP ≥2 mg/L, rosuvastatin significantly reduced first MI, stroke, arterial revascularization, hospitalization for unstable angina, and cardiovascular death among whites and nonwhites.
Perspective:
Blacks and Hispanics have been under-represented in the lipid-lowering trials. That the JUPITER strategy with rosuvastatin was equally effective in whites and nonwhites adds to large body of evidence supporting statins in primary prevention. However, it should be noted that the reduction in primary endpoints was not statistically significant in blacks or Hispanics. The latter possibly reflects inadequate median follow-up, particularly in blacks, as seen in the Kaplan-Meier curves in Figure 2 of this article.
Keywords: Fluorobenzenes, Ethnic Groups, Myocardial Infarction, Stroke, Follow-Up Studies, Cholesterol, LDL, Risk Reduction Behavior, Hydroxymethylglutaryl-CoA Reductase Inhibitors, European Continental Ancestry Group, Pyrimidines, Blood Pressure, Hispanic Americans, Primary Prevention, Lipoproteins, LDL, Cholesterol, C-Reactive Protein, Body Mass Index, Cardiovascular Diseases, Confidence Intervals, Triglycerides, Hypertension, Sulfonamides
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