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VIEWPOINT AND COMMENTARY

Statins in Acute Coronary Syndromes

Do the Guideline Recommendations Match the Evidence?

Ryan P. Morrissey, MD^_*, George A. Diamond, MD^_*, and Sanjay Kaul, MD^_*,,,_*

^_* Cedars-Sinai Medical Center, University of California, Los Angeles, Los Angeles, California
Division of Cardiology, University of California, Los Angeles, Los Angeles, California
David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
Cedars-Sinai Heart Institute, Los Angeles, California

Manuscript received December 23, 2008; revised manuscript received March 25, 2009, accepted April 14, 2009.

^_* Reprint requests and correspondence: Dr. Sanjay Kaul, Division of Cardiology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048 (Email: kaul{at}cshs.org).

On the basis of the evidence obtained from observational studies, randomized controlled trials and their meta-analyses, current guidelines recommend initiating high-dose statin therapy pre-discharge regardless of the baseline low-density lipoprotein (LDL) level in patients with acute coronary syndromes (ACS). Careful review of the evidence indicates that early initiation of high-dose statin therapy reduces recurrent ischemia and may reduce revascularization, but does not confer benefit in terms of hard clinical outcomes such as death or myocardial infarction in any of the randomized controlled trials, and may be associated with increased liver and muscle-related adverse outcomes leading to increased withdrawal and suboptimal long-term adherence. A mortality benefit is apparent in pooled analyses of randomized controlled trials only at long-term (24-month) but not short-term (4-month) follow-up. The critical role of the timing of initiation of therapy (early vs. late) on the benefit-risk profile of statin treatment has not been systematically assessed. It is unclear whether the clinical benefits are attributable to lipid-lowering or lipid-lowering–independent effects. Finally, an optimal LDL threshold for initiating treatment or target LDL level for treatment in ACS remains yet to be defined. On the basis of these observations, and despite a compelling pathophysiologic rationale, the justification for current Class I, Level of Evidence: A recommendation for statin therapy in patients with ACS remains open to question.

Key Words: statins • low-density lipoprotein • unstable angina • myocardial infarction • guidelines • cardiovascular outcomes

Abbreviations and Acronyms   ACS = acute coronary syndromes   CHD = coronary heart disease   LDL = low-density lipoprotein   MI = myocardial infarction

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J. Am. Coll. Cardiol. 2009 54: A26. [Full Text] [PDF]