The extent to which statins have improved cardiovascular outcomes: Lessons from randomized trials and observational studies of "real world" practice in people with diabetes.

Statins are the mainstay of therapy for cardiovascular risk reduction in patients with diabetes mellitus. It is estimated that there are more than half a billion patients with diabetes mellitus worldwide and the numbers of prevalent cases of diabetes are expected to increase in both developed and developing countries in the next decade. Statins reduce risk of mortality and morbidity mainly by reducing blood low density cholesterol. Statins, along with other medical treatments, are responsible for about half of the decrease in cardiovascular mortality over the past several decades. Multiple clinical trials have found evidence for statin use in patients with diabetes, for both primary prevention and secondary prevention. The benefit of statins in patients with coronary heart disease and diabetes in terms of absolute risk reduction is twice as much as compared to the risk in patients with coronary heart disease but no diabetes. The proportion of patients with diabetes treated with statins has increased steadily over the past few decades with concurrent decrease in cardiovascular deaths in this high-risk population. However, there are significant unmet needs in cardiovascular risk reduction, due to underutilization of statins and due to residual cardiovascular risk despite maximal statin therapy. Future strategies in population risk reduction in diabetics should include maximal statin therapy, additional treatment with nonstatin therapy and new paradigms of prevention with early intervention with shorter, more intensive therapy to potentially "reverse" atherosclerosis with goals of reducing clinical cardiovascular disease later in life.