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VIEWPOINT AND COMMENTARY

Early Statin Therapy in Acute Coronary Syndromes

The Successful Cycle of Evidence, Guidelines, and Implementation

Division of Cardiology, San Francisco General Hospital, San Francisco, California; and the University of California, San Francisco School of Medicine, San Francisco, California

Manuscript received May 6, 2009; accepted May 11, 2009.

^_* Reprint requests and correspondence: Dr. David D. Waters, Division of Cardiology, Room 5G1, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, California 94114 (Email: dwaters{at}medsfgh.ucsf.edu).

That statins should be prescribed for patients before hospital discharge after an episode of acute coronary syndrome (ACS) is a Level of Evidence: 1A recommendation of the American College of Cardiology/American Heart Association Joint Task Force. This level of recommendation is based upon 2 clinical trials: the MIRACL (Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering) and PROVE-IT (Pravastatin or Atorvastatin Evaluation and Infection Therapy) trials. In the MIRACL trial, 3,086 patients with unstable angina or non–Q-wave myocardial infarction were randomized within 4 days of the event to atorvastatin 80 mg/day or to placebo and followed for 16 weeks. The primary composite end point occurred in 14.8% of atorvastatin patients and 17.4% of placebo patients, a 16% relative risk reduction (p = 0.048). In the PROVE-IT trial, 4,162 patients hospitalized with an ACS within the preceding 10 days were randomized to atorvastatin 80 mg/day or pravastatin 40 mg/day and were followed for a mean of 24 months. The primary event rate was 22.4% in the atorvastatin group and 26.3% in the pravastatin group, a 16% relative risk reduction (p = 0.005). A strong trend toward a reduction in total mortality was seen in the atorvastatin group (2.2% vs. 3.2%, p = 0.07). Using a composite end point of death, myocardial infarction, and rehospitalization for ACS, the difference between the treatment groups is already statistically significant at 30 days and remains so throughout the follow-up period. Comprehensive treatment programs in ACS patients that include initiation of statins before hospital discharge have been shown to improve outcomes such as recurrent myocardial infarction and total mortality at 1 year. Guidelines prove their utility when their implementation improves outcomes across a broad population at risk, such as in this instance.

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

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

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