Hoy en día, disponemos de 7 estatinas. La pitavastatina, la estatina más nueva, parece tener ventajas significativas para el paciente que no ha tolerado otras estatinas. Además, causa una menor disminución de la coenzima Q-10 que puede resultar en un riesgo menor de miopatía. La pitavastatina no depende del citocromo P450 para su metabolismo y esto disminuye el riesgo de alteraciones metabólicas; y existe la posibilidad de un mayor aumento en la lipoproteína de alta densidad, en comparación con otras estatinas. Su uso parece justificado en algunas circunstancias y es posible que el fármaco tenga un nicho único en la disminución del riesgo cardiovascular.

There are currently 7 statins available in clinical practice. Pitavastatin is the newest statin and it appears to have significant advantages for the patient who has not tolerated other statins. With pitavastatin, there is a smaller decrease in coenzyme Q-10 which may diminish the risk of myopathy. Also, pitavastatin does not depend on cytochrome P450 for its metabolism and this decreases the risk for metabolic alterations. In addition, pitavastatin offers the possibility of a larger increase in high density lipoproteins. Therefore, its usage appears justified in certain circumstances and it appears that pitavastatin may have a unique niche in decreasing cardiovascular risk.

All statins inhibit hydroxymethylglutaryl Coenzyme A Reductase but each has a different chemical structure that may have individual advantages. Some pharmaceutical companies have minimized side effects and stated that dose has no relation to incidence. To the contrary, dose is related to side effects with all statins. Myopathy occurs in up to 10.5% of patients taking a high dose. There is an attempt to sell statins that have lost patent protection over-the-counter. However, evidence supports medical supervision as offering greatest patient safety. Concerns were raised about ezetimibe after the initial ENHANCE (effcacy) and SEAS (cancer risk) study but these concerns appear to have been answered. Fenofbrate can be used with a statin but gemfbrozil is contraindicated. Coenzyme Q-10 possibly helps to mitigate the risk of myopathy with a statin but evidence is not universally accepted. JUPITER represented a valid outcomes study but made a claim that rosuvastatin has special value in risk management because of decreased high sensitivity C-Reactive Protein. This actually occurs with any statin, a decrease also enhanced by ezetimibe. Statins have benefted the lives of our patients but, as with any treatment, the physician needs to look critically at all the problems and claims made.

A 3 los factores de riesgo cardiovascular (CV) tradicionales hipercolesterolemia, hipertensión y tabaquismo, se agregó la diabetes mellitus. Hay muchos otros como la homocisteína y la lipoproteína(a), aunque de los beneficios de su tratamiento están por aclararse. También hay interés en los factores inflamatorios de riesgo CV, como la proteína C-reactiva ultra sensible (PCR-us) y la lipasa A2 asociada a las lipoproteínas (Lp-PLA2) cuyo dosaje está disponible comercialmente pero no es claro su rol en la práctica clínica de rutina. Sin embargo, todavía las lipoproteínas de baja densidad (LDL) representan el estándar de oro para predecir el riesgo CV. Con las dislipidemias de lipoproteínas específicas y los pacientes de difícil manejo, es importante individualizar su tratamiento con dietas y fármacos alternativos. Existieron percepciones erróneas como la creencia que solamente los caucásicos del mundo occidental y los varones tenían riesgo CV significativo. Ahora se sabe que muchos otros grupos étnicos también sufren enfermedades CV, especialmente los que viven en población urbana y que las mujeres incluso tienen peor pronóstico si se presentan antes de los 50 años de edad. Quizás el problema médico más importante en este momento es el síndrome metabólico, que en combinación junto a los demás factores de riesgo CV multiplica el riesgo total. Los tratamientos futuros involucrarán a la genética pero, por ahora, el uso agresivo de medicamentos puede modificar favorablemente el riesgo CV, más no eliminarlo.

To the 3 major traditional risk factors for cardiovascular (CV) disease consisting of hypercholesterolemia, hypertension and cigarette smoking, an essentially equal fourth can be added, namely diabetes mellitus. There are many other risk factors such as elevated levels of homocysteine and lipoprotein (a) but the benefit of their treatment remains to be clarified. Also, there is an interest in inflammatory risk factors for CV disease such as high sensitivity C-reactive protein and lipoprotein-associated phospholipase A2, the measurement of both is commercially available, however their role in routine clinical practice is not clearly established. Therefore, low density lipoproteins (LDL) remain the gold standard to predict CV risk. For dyslipidemias involving specific lipoproteins and for patients that are difficult to manage, it is important to individualize the treatment with specific diets and targeted medications. There exist erroneous perceptions in CV medicine such as the thought that only caucasians of the Western World and males have a significant CV risk. However, it is now known that many other ethnic groups also suffer from various CV diseases, especially in urban populations. Also, women as a group have a worse prognosis than men if they present with a myocardial infarction before the age of 50. Perhaps the most important medical problem of the current era is the metabolic syndrome in which the combination of multiple CV risk factors multiplies the total CV risk. Future management of CV disease will involve genetics but for now, the aggressive use of medications may not eliminate CV risk but can very favorably modify the severity and clinical significance of that risk and lead to better clinical outcomes. Key-words: Atherosclerosis, vascular disease, cardiovascular risk factors, inflammation, high density lipoproteins, low density lipoproteins, very low density lipoproteins, metabolic syndrome.