The Jupiter Trial - Cholesterol and CRP
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Jupiter is a big planet and the Jupiter study seems to have had a big impact on the cardiac world. In the study with 17802 healthy men and women whose LDL cholesterol was below 130 and C-reactive Protein levels above 2 were assigned to either the statin drug Crestor or placebo. LDL cholesterol is what is called bad cholesterol and generally one wants to keep it below 130; however, for people with known coronary heart disease current thinking aims for LDL cholesterol levels of 70. C-Reactive Protein was discovered in 1930's as a protein substance that reacted with the C polysaccharide of the pneumococcus bacterium. CRP is a 224-residue protein, which is synthesized in the liver, and liver failure can interfere with its production. CRP is used as a marker of inflammation in the body. Usually, viral infections tend to give lower elevations in CRP than bacterial infections. In cardiology a high sensitivity CRP test is used to differentiate between what would normally be considered lower levels. A level above 2.4 mg/l has been associated with about double the risk of a coronary event compared to a level below 1.0. It is also known that CRP levels tend to rise as waist circumference increases. A 2008 study showed that CRP is not an active participant in atherogenesis since people with high levels of various genetic CRP variants had no increased risk of cardiovascular disease compared to those with normal CRP. Testing for cardiac purposes should be avoided when one has an infectious disease.
In the study the LDL cholesterol in the Crestor group was reduced by 50% and CRP levels by 37%. Thirty-one patients in the Crestor group had any heart attack while sixty-eight had one in the placebo group. The median follow-up period was about two years. Strokes were also reduced from sixty-four to thirty-three. Deaths were reduced from 247 to 198. Side effects were generally the same in both groups except that physician reported newly diagnosed diabetes was 270 in Crestor group versus 216 in placebo and this was statistically significant. However, fasting glucose in the two groups was the same at the end of the study. The study was stopped because of the excellent results but it would be interesting to know effects of longer-term treatment. It was necessary to treat about 9000 people to prevent 30-40 heart attacks and strokes however one can assume that for the others you prevented the further development of plaque which would show benefit further down the road. Complicating the study was the fact that about 16 percent were current smokers and it would be interesting in subgroup analysis to find out what percentage of those who had a heart attack or stroke were smokers. Thus CRP elevations in conjunction with other aspects of the patients overall risk should give the physician an indication of when to begin cholesterol lowering in otherwise healthy individuals with LDL of less than 130. It may also be that we will eventually recommend LDL less than 100 for all patients over 40.
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