http://www.theheart.org/web_slides/1136565.do A prospective,randomized, open-label, blinded-end-point evaluation trial on incremental decrease in endpoints through aggressive lipid lowering (IDEAL) using patients with a history of acute MI

1. IDEAL (Incremental Decrease in
Endpoints through Aggressive Lipid
Lowering)

2. IDEAL (Incremental Decrease in Endpoints through
Aggressive Lipid Lowering)
T Pedersen (Ullevål University Hospital, Oslo, Norway)
American Heart Association 2005 Scientific Sessions
• Background:
IDEAL is a "lower-is-better" investigation comparing high-dose atorvastatin
(80 mg) with simvastatin 20 mg, a dose widely used in clinical practice
• A prospective, randomized, open-label, blinded-end-point evaluation trial
• Population:
8888 patients aged 80 years or younger with a history of acute MI
• Primary outcome:
Composite of coronary death, nonfatal MI, or cardiac arrest with
resuscitation

3. IDEAL: Results
• At a five-year follow-up mean LDL-C was 80.0 mg/dL in atorvastatin patients
and 99.8 mg/dL in simvastatin patients
• There was no statistical difference in the incidence of the primary end point
between the two arms
Primary outcomea
Outcome (%) Simvastatin (n=4449) Atorvastatin (n=4439) Hazard ratio
(95% CI)
Major coronary eventb 10.4 9.3 0.89 (0.78–1.01)
CHD death 4.0 3.9 0.99 (0.80–1.22)
Nonfatal MI 7.2 6.0 0.83 (0.71–0.98)
Cardiac arrest with resuscitation 0.2 0.2 NA
a. At a median of 4.8 years
b. Coronary death, nonfatal MI, or cardiac arrest with resuscitation

4. IDEAL: Results
• The composite secondary end point of a major CV eventa was significantly
reduced in patients treated with atorvastatin
Secondary outcomesb
Outcome (%) Simvastatin (n=4449) Atorvastatin (n=4439) Hazard ratio
(95% CI)
Any CHD event 23.8 20.2 0.84 (0.76–0.91)
Coronary revascularization 16.7 13.0 0.77 (0.69–0.86)
Hospitalization for unstable angina 5.3 4.4 0.83 (0.69–1.01)
Fatal or nonfatal stroke 3.9 3.4 0.87 (0.70–1.08)
Major CV event 13.7 12.0 0.87 (0.78–0.98)
Any CV event 30.8 26.5 0.84 (0.78–0.91)
a. Major coronary events and stroke
b. At a median of 4.8 years

5. IDEAL: Commentary*
"Nothing magical seems to happen here that would make us shift our focus away
from LDL-lowering effects. The important point is to lower LDL cholesterol to
sufficiently low levels to provide incremental benefit."
- Dr James de Lemos
"Saying that it is difficult is not saying that we shouldn't try. . . . What the guidelines
are really telling clinicians is to get the LDL cholesterol down as low as you safely
can."
- Dr Steven Nissen
*All comments from IDEAL: Intensive lipid lowering after acute MI did not reduce the risk of major
coronary events (http://www.theheart.org/article/598723.do)

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