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In Reply: Drs Ravnskov and Sutter suggest that we should have examined lumen area rather than atheroma volume. We disagree. Most myocardial infarctions occur at sites without flow-limiting lesions.¹ Atherosclerosis is a disease of the vessel wall not the lumen. Remodeling preserves lumen size throughout much of the course of coronary disease.² We used intravascular ultrasound because it enables precise quantification of coronary plaque in vivo. While we concur with Ravnskov and Sutter that nonlipid (eg, anti-inflammatory) effects may partially explain the superior outcome observed in patients who received atorvastatin, we think the evidence also strongly supports the benefits of greater lowering of LDL cholesterol. We plan to perform additional multivariate analyses to explore the contributions of lipid and nonlipid effects.

Ravnskov and Sutter also claim that a dose-response relationship has not been found in prior trials. Again, we disagree. In fact, the hypothesis has not been tested previously. Prior . . . [Full Text of this Article]

Steven Nissen, MD
nissens@ccf.org
Department of Cardiovascular Medicine
Cleveland Clinic Foundation
Cleveland, Ohio

For the REVERSAL Investigators

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