Early, intensive statin therapy reduces risk of death and cardiac events in patients hospitalized for ACS

Intensive statin therapy administered to patients within 14 days of hospitalization for acute coronary syndrome (ACS) can reduce the risk of death and certain cardiovascular events by nearly 20%, according to a meta-analysis by Eddie Hulten, MD, MPH, and colleagues recently published in Archives of Internal Medicine.

This meta-analysis pooled the results of 13 randomized, controlled trials of various statins (atorvastatin, simvastatin, pravastatin, and fluvastatin), evaluating a total of 17,963 patients (mean age, 60 years; 76% male) recently hospitalized for ACS (unstable angina or non-ST-segment elevation myocardial infarction). To be included in this meta-analysis, trials had to have compared high-intensity statin therapy with either lower-intensity or no statin therapy administered within 2 weeks of hospitalization for ACS. The primary end point of this analysis, which was evaluated at 1, 4, 6, 12, and 24 months of therapy, was the combined incidence of death and cardiac events (recurrent ischemia or recurrent myocardial infarction).

Early, intensive statin therapy did not demonstrate any benefit at 1 month (HR=1.02; 95% CI, 0.95–1.09) or 4 months (HR=0.84; 95% CI, 0.72–1.02), but by the sixth month, a statistically significant reduction in the combined end point was observed (HR=0.76; 95% CI, 0.70–0.84), and this reduction persisted through 24 months (HR=0.81; 95% CI, 0.77–0.87). The authors stated that the failure of early, intensive statin therapy to demonstrate a benefit before 6 months "may not be a surprising finding since one potential benefit of statins may be plaque stabilization, which may take several months to occur."

The meta-analysis by Hulten and colleagues also evaluated the effects of early, intensive statin therapy on individual cardiac end points. Over 24 months, there was a reduction in cardiac death (HR=0.76; 95% CI, 0.66–0.87) and recurrent ischemia (HR=0.68; 95% CI, 0.50–0.92) but only a trend toward a reduction in the incidence of recurrent myocardial infarction (HR=0.89; 95% CI, 0.60–1.33). The authors stated, "This inconsistency was not anticipated. We would have expected that for statins to have benefits with regard to all-cause mortality, the intervention should likewise have reduced the rate of recurrent MI."

Despite this finding, the authors stated that this meta-analysis "suggests that there might be a role for early, intensive therapy, though the benefits will take several months to begin to accrue."

Currently, the American College of Cardiology (ACC) guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction do not make a universal recommendation for early, intensive statin therapy.

SOURCES Hulten E, Jackson JL, Douglas K, George S, Villines TC. The effect of early, intensive statin therapy on acute coronary syndrome. Arch Intern Med. 2006;166:1814–1821.

Briel M, Schwartz GG, Thompson PL, et al. Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes: a meta-analysis of randomized controlled trials. JAMA. 2006;295:2046–2056.

Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366–1374.