Starting statins post MI
When should statins be started in patients who have
had a myocardial infarction?
Current guidelines suggest waiting three months,
but doctors are now starting to believe that early treatment, at the time
of the infarct, might be beneficial. They argue that this could take advantage
of possible non-lipid statin actions.
In a presentation to the 3rd International Cerivastatin
Conference on 30 June, Dr Wouter Jukema, Leiden University Medical Centre,
the Netherlands, said that although statins had an established place in
treating stable coronary atherosclerosis, in acute MI the focus was on
use of beta-blockers and antithrombotics/anticoagulants. Yet observational
studies suggested that use of statins at the time of hospital admission
and/or discharge was associated with improved short-and intermediate-term
survival.
There was a solid hypothesis for benefit, he said.
Several statins had been reported to improve endothelial dysfunction,
reduce lipid deposition, reduce inflammation and reduce plaque rupture
and thrombus formation. The drugs might therefore improve early reperfusion
which could reduce infarct size and also lead to a reduction in congestive
heart failure. “Having a plausible hypothesis is not enough and we should
wait for the results of randomised trials to settle the matter,” Dr Jukema
said.
These trials are now under way. Dr Jean-Marc Lablanche,
head of the interventional cardiology department, University Hospital
of Lille, France, said that one trial had been reported already, the MIRACL
study (with atorvastatin), and validated the concept of early statin use.
Two other large trials were in progress. The A-to-Z
trial involved patients with unstable angina or non-Q wave MI who, after
initial randomisation to tirofiban or placebo, were being randomised to
simvastatin or placebo. In the PRINCESS trial, patients were being randomised
within 48 hours of acute MI to cerivastatin or placebo. Dr Lablanche described
PRINCESS as a “real world” study since there was no upper age limit, no
heart failure exclusion and, because the investigators were looking at
non-lipid lowering effects, no lipid limit for trial entry.
Another statin question being investigated in trials
is how low to go with LDL cholesterol levels. Professor Neil Poulter,
professor of preventive cardiovascular medicine, Imperial College, London,
believed that “the lower the better” was likely to give best value, though
with a degree of diminishing return. But, he said, there were more immediate
concerns than the LDL targets: “The majority of patients who need lipid
lowering in the UK are not being treated at all.” It was vital to get
the message across about the national service framework recommendations
on coronary heart disease prevention.
— Contributed
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