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Original Articles

Number Needed to Treat With Rosuvastatin to Prevent First Cardiovascular Events and Death Among Men and Women With Low Low-Density Lipoprotein Cholesterol and Elevated High-Sensitivity C-Reactive Protein

Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER)

Paul M Ridker, MD; Jean G. MacFadyen, BA; Francisco A.H. Fonseca, MD; Jacques Genest, MD; Antonio M. Gotto, MD; John J.P. Kastelein, MD; Wolfgang Koenig, MD; Peter Libby, MD; Alberto J. Lorenzatti, MD; Børge G. Nordestgaard, MD; James Shepherd, MD; James T. Willerson, MD; Robert J. Glynn, ScD for the JUPITER Study Group

From the Center for Cardiovascular Disease Prevention (P.M.R., E.D., J.M., R.J.G.) and the Division of Cardiovascular Medicine (P.M.R., P.L.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass; Universidade Federal de Sao Paulo (F.F.), Sao Paulo, Brazil; McGill University Health Center (J.G.), Montreal, Quebec, Canada; Weill Medical College of Cornell University (A.G.), New York; Academic Medical Center (J.K.), University of Amsterdam, the Netherlands; University of Ulm (W.K.), Germany; Hospital Cordoba (A.J.L.), Argentina; Herlev Hospital, Copenhagen University Hospital (B.G.N.), University of Copenhagen, Denmark; University of Glasgow (J.S.), Scotland; and St Luke’s Episcopal Hospital/Texas Heart Institute (J.T.W.), Houston, Tex.

Correspondence to Dr Ridker, MD, Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital, 900 Commonwealth Ave E, Boston, MA 02215. E-mail pridker{at}partners.org

Received January 2, 2009; accepted August 19, 2009.

Background— As recently demonstrated, random allocation to rosuvastatin results in large relative risk reductions for first cardiovascular events among apparently healthy men and women with low levels of low-density lipoprotein cholesterol but elevated levels of high-sensitivity C-reactive protein. However, whether the absolute risk reduction among such individuals justifies wide application of statin therapy in primary prevention is a controversial issue with broad policy and public health implications.

Methods and Results— Absolute risk reductions and consequent number needed to treat (NNT) values were calculated across a range of end points, timeframes, and subgroups using data from Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER), a randomized evaluation of rosuvastatin 20 mg versus placebo conducted among 17 802 apparently healthy men and women with low-density lipoprotein cholesterol <130 mg/dL and high-sensitivity C-reactive protein 2 mg/L. Sensitivity analyses were also performed to address the potential impact that alternative statin regimens might have on a similar primary prevention population. For the end point of myocardial infarction, stroke, revascularization, or death, the 5-year NNT within JUPITER was 20 (95% CI, 14 to 34). All subgroups had 5-year NNT values for this end point below 50; as examples, 5-year NNT values were 17 for men and 31 for women, 21 for whites and 19 for nonwhites, 18 for those with body mass index 25 kg/m² and 21 for those with body mass index greater than 25 kg/m², 9 and 26 for those with and without a family history of coronary disease, 19 and 22 for those with and without metabolic syndrome, and 14 and 37 for those with estimated Framingham risks greater or less than 10%. For the net vascular benefit end point that additionally included venous thromboembolism, the 5-year NNT was 18 (95% CI, 13 to 29). For the restricted "hard" end point of myocardial infarction, stroke, or death, the 5-year NNT was 29 (95% CI, 19 to 56). In sensitivity analyses addressing the theoretical utility of alternative agents, 5-year NNT values of 38 and 57 were estimated for statin regimens that deliver 75% and 50% of the relative benefit observed in JUPITER, respectively. All of these calculations compare favorably to 5-year NNT values previously reported in primary prevention for the use of statins among hyperlipidemic men (5-year NNT, 40 to 70), for antihypertensive therapy (5-year NNT, 80 to 160), or for aspirin (5-year NNT, >300).

Conclusions— Absolute risk reductions and consequent NNT values associated with statin therapy among those with elevated high-sensitivity C-reactive protein and low low-density lipoprotein cholesterol are comparable if not superior to published NNT values for several widely accepted interventions for primary cardiovascular prevention, including the use of statin therapy among those with overt hyperlipidemia.

Clinical Trial Registration— clinicaltrials.gov. Identifier NCT00239681.

Key Words: statins • outcomes research • prevention and control • epidemiology • primary prevention • risk factors

Guest Editor for this article was Gregory Y.H. Lip, MD.