Lipid-lowering therapy reduces mortality rates after acute coronary syndromes

In Brief

In a randomized, double-blind trial the lipid-lowering agent atorvastatin administered between 24 and 96 hours after hospital admission reduced the incidence of recurrent ischemic events in the first 16 weeks, while an observational study of patients who received lipid-lowering therapy at hospital discharge found a significant reduction of early mortality rates.

The atorvastatin study showed a relative risk reduction of 16 percent in the incidence of death, cardiac arrest, MI, or worsening unstable angina requiring emergency hospitalization, and a significant decline of the mean low-density lipoprotein cholesterol level.

Using data pooled from two large international randomized trials adjusted for possible confounders, the observational study found that the lipid-lowering therapy was associated with a 33 percent reduction in all-cause mortality at 6 months, but not with a reduction of MI rate.

These results suggest that lipid-lowering drugs confer a survival benefit in the early period following acute coronary syndromes of unstable angina and non-Q-wave MI, and argue for their routine use in this setting.

Praxis.MD Recommendations
Reviewed by James L. Ritchie, MD, Professor of Medicine at Seattle's University of Washington School of Medicine, and Cardiology Editor, Best Practice of Medicine

Be aware of the unstable clinical state that follows an acute coronary disease event of unstable angina or non-Q-wave myocardial infarction: Patients experience a high rate of serious complications including death, MI, and progressively recurring unstable angina requiring intervention. The incidence rate sharply declines after 1 month, and then gradually diminishes so that after about 6 months, the incidence of coronary death and MI is fairly constant for the next several years.

Consider starting statin therapy prior to discharge. These studies suggest they are associated with reduced 6-month mortality and a significant decline in recurrent symptomatic ischemic events requiring emergency hospitalization, even as early as 30 days following the initiation of treatment. While these studies are limited and the results need further confirmation, contemporary lipid-lowering agents have already proven their safety, tolerability, and cost-effectiveness for the secondary prevention of coronary disease.

Initiate treatment with standard doses of a statin lipid-lowering agent: The extent of LDL cholesterol level reduction is not associated with the magnitude of reduction in coronary events

Use a lipid profile measured during the past year or two before the acute coronary syndrome to determine therapy, according to routine secondary prevention guidelines.

In patients with unknown lipid levels before the event, institute a default, interim plan prescribing a statin at standard dosing. After 3 months of therapy, fine-tune the treatment using the patient's specific lipid profile.

In addition to pharmacologic lipid therapy, the treatment plan should include diet changes to lower LDL cholesterol levels and blood pressure, and appropriate exercise regimens.

References and Links

• Schwartz GG, Olsson AG, Ezekowitz MD, et al.: Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: The MIRACL study: a randomized controlled trial. JAMA. 2001 Apr 4;285(13):1711-8. [abstract ] [editorial ]
• Aronow HD, Topol EJ, Roe MT, et al.: Effect of lipid-lowering therapy on early mortality after acute coronary syndromes: an observational study. Lancet. 2001 Apr 7;357(9262):1063-8. [abstract ]
• In Best Practice of Medicine see Approach to patient with hyperlipidemia, Q-Wave Myocardial Infarction, and Non-ST Elevation Acute Coronary Syndromes.
• The American Heart Association http://www.americanheart.org/ .
• May 1998 JAMA Antiatherothrombotic properties of statins - Implications for cardiovascular event reduction http://jama.ama-assn.org.
• Atorvastatin: a review of its pharmacology and place in therapy.
• Virtual Hospital University of Iowa - http://www.vh.org.