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Management of Hyperlipidemia in Patients With Abdominal Aortic Aneurysm
IN RESPONSE:
I thank Dr. Sethi for pointing out this omission, because the recommendation merits discussion. Treatment of patients with occlusive vascular disease with statins is based on convincing data from randomized trials. No such data are available to support lipid lowering in patients with AAA without known occlusive disease. The ATP III classified AAA as a “clinical form of non-coronary atherosclerosis” (1). Few AAA investigators would agree with this, because a large body of evidence (2) increasingly suggests a distinct genetic and immune cause, most clearly differentiated from atherosclerosis by the negative association of AAA with diabetes.
The only evidence cited in support of the ATP III recommendation was the article by Hertzer (3), an observational study that included 105 patients without a history of CHD who had AAA repair between 1969 and 1973 and in whom 15 late coronary deaths occurred up to 11 years after repair. This study does not reflect modern diagnosis and management, and it is not surprising that some coronary deaths should occur in a group of mostly elderly male smokers. The same is true for other conditions, such as chronic obstructive pulmonary disease (COPD). The prevalence of a history of myocardial infarction in men with AAA in a large screening study (32%) (4) was similar to that of men with COPD in a national sample (27%) (5). The ATP III correctly makes no recommendation for lipid lowering in COPD and should not recommend it for AAA without convincing evidence from randomized trials.
Aside from the risk for overtreatment, the ATP III's recommendation has the drawback of impeding further investigation. Preliminary observational data (6) suggest a possible benefit from statins in reducing AAA enlargement. However, in 2002, the manufacturer of simvastatin declined to provide placebo tablets for a randomized trial intended to test this effect, citing the ATP III recommendation as its reason.
Article and Author Information
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Potential Conflicts of Interest: None disclosed.
