Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels

HMG-CoA reductase inhibition improves endothelial cell function and inhibits smooth muscle cell proliferation in human saphenous veins

OBJECTIVES

This study examined effects of 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase inhibitor cerivastatin on human saphenous vein (SV), endothelial cells (EC) and smooth muscle cells (SMC).

BACKGROUND

Venous bypass graft failure involves EC dysfunction and SMC proliferation. Substances that improve EC function and inhibit SMC proliferation would be of clinical relevance.

METHODS

Both EC and SMC were isolated from SV. Endothelial nitric oxide synthase (eNOS) expression and nitric oxide (NO) production were analyzed by immunoblotting and porphyrinic microsensor. The SMC proliferation was assayed by 3H-thymidine incorporation. Protein kinases and cell cycle regulators were analyzed by immunoblotting.

RESULTS

Cerivastatin (10(-9) to 10(-6) mol/liter) enhanced eNOS protein expression and NO release (about two-fold) in EC in response to Ca2+ ionophore (10(-6) mol/liter). This was fully abrogated by the HMG-CoA product mevanolate (2 x 10(-4) mol/liter). In SMC, platelet-derived growth factor (5 ng/ml) enhanced 3H-thymidine incorporation (298 +/- 23%, n = 4), activated cyclin-dependent kinase (Cdk2), phosphorylated Rb and down-regulated p27Kip1 (but not p21CiP1). Cerivastatin reduced the 3H-thymidine incorporation (164 +/- 11%, p < 0.01), inhibited Cdk2 activation and Rb phosphorylation, but did not prevent p27Kip1 down-regulation, nor p42mapk and p70S6K activation. Mevalonate abrogated the effects of cerivastatin on Cdk2 and Rb but only partially rescued the 3H-thymidine incorporation (from 164 +/- 11% to 211 +/- 13%, n = 4, p < 0.01).

CONCLUSIONS

In humans, SVEC inhibition of HMG-CoA/mevalonate pathway contributes to the enhanced eNOS expression and NO release by cerivastatin, whereas in SMC, inhibition of this pathway only partially explains cerivastatin-induced cell growth arrest. Inhibition of mechanisms other than p42mapk and p70S6K or Cdk2 are also involved. These effects of cerivastatin could be important in treating venous bypass graft disease.

Novel lipid-regulating drugs

This review describes the major developments in lipid-regulating drugs during the past two years. Most of the novel compounds that have been launched or were in their final stages of development during this period are aimed primarily at lowering low-density lipoprotein (LDL)-cholesterol. These include bile acid sequestrants, HMG-CoA reductase inhibitors and a cholesterol absorption inhibitor. In addition, there have been preclinical reports suggesting the potential usefulness of orally bioavailable inhibitors of cholesterol ester transfer protein in plasma and of acylcoA:cholesterol acyltransferase in monocyte-macrophages. The recent discovery of the roles of the scavenger receptor class B Type 1 and ATP-binding cassette transporter 1 in high-density lipoprotein (HDL)-cholesterol transport may shift the trend of future developments away from compounds that lower LDL to those aimed at promoting HDL turnover.

Coronary artery injury and the biology of atherosclerosis: inflammation, thrombosis, and stabilization

Conventional concepts of the pathogenesis of acute coronary syndromes are changing. High-risk lesions are not necessarily the angiographically "tight" stenoses. Rather, unstable vulnerable lesions have large lipid cores and thin fibrous caps. Plaque instability relates closely to the development of inflammation within the intima. Acute coronary syndromes usually result from rupture of a vulnerable atherosclerotic plaque mechanistically linked to the inflammatory process. Stabilization of lesions, rather than percutaneous or surgical procedures, provides a new therapeutic target. Lipid lowering may stabilize lesions by mitigating the inflammatory response.

Medical therapy of unstable angina and non-Q-wave myocardial infarction

Management of acute coronary syndromes has been the focus of increased interest in recent years. This has come about with the recognition that the majority of patients who present to the hospital with chest pain have unstable angina or non-Q-wave myocardial infarction (MI). Further, sensitive biochemical markers of myocardial necrosis, such as troponin and creatine kinase, have improved early diagnosis. Markers of inflammation such as C-reactive protein (CRP), although not in wide clinical practice, may provide an early and important marker of prognosis. The current approach to management of acute coronary syndromes is careful risk stratification so as to select appropriate medical therapies and to guide the clinician to appropriate interventions such as angiography or percutaneous coronary intervention (PCI). Established therapies such as aspirin, heparin, intravenous nitrates, and, in selected patients, beta blockers or calcium antagonists, are being used concomitantly with, or are being supplanted by, newer therapies such as low-molecular-weight heparins and glycoprotein IIb/IIIa inhibitors. The role of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) in patients with acute coronary syndromes is being investigated and shows promise.

Exploring new strategies for the management of acute coronary syndromes

Patients who present today with an acute coronary syndrome face a substantially lower risk of death, recurrent myocardial infarction, or severe ischemia than patients did a decade ago. Researchers are pursuing new strategies to further improve the outcomes of patients with acute coronary syndromes. These strategies may be grouped into 3 paradigms: (1) restoration and maintenance of coronary flow at the site of culprit lesion; (2) reduction of infarct size, reperfusion injury, and postischemic dysfunction; (3) stabilization of the coronary arterial wall and its interaction with the bloodstream to reduce recurrent ischemic events. The last approach encompasses strategies to alter the underlying vascular pathophysiology that leads to plaque instability and coronary thrombosis. Investigation into each of these paradigms may yield new strategies that will be incorporated into standard clinical management of acute coronary syndromes in coming years. With so many mechanistically different approaches to the management of acute coronary syndromes, clinicians have reason for optimism that continued progress will further reduce the morbidity and mortality associated with acute coronary syndromes and the likelihood of their recurrence.

Should intensive cholesterol lowering play a role in the management of acute coronary syndromes?

Although several large, well-controlled trials with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) demonstrate the benefits of cholesterol lowering on cardiovascular morbidity and mortality, these trials excluded patients with recent unstable angina or myocardial infarction. Thus, the potentially beneficial effects that may accrue from early statin therapy have not been apparent. Mechanistic and experimental studies show that benefits from statin therapy may include improved endothelial function, a decrease in platelet thrombus deposition, and a reduction in inflammation at the site of the lesion. Large-scale clinical trials are now under way to determine the effect of aggressive cholesterol lowering in patients with acute coronary syndromes. If the findings of the smaller studies are confirmed, statin therapy should be considered early after infarction or unstable angina.

Effect of pravastatin on coronary disease events in subgroups defined by coronary risk factors: the Prospective Pravastatin Pooling Project

BACKGROUND

Previous trials have had insufficient numbers of coronary events to address definitively the effect of lipid-modifying therapy on coronary heart disease in subgroups of patients with varying baseline characteristics.

METHODS AND RESULTS

The data from 3 large randomized trials with pravastatin 40 mg were pooled and analyzed with the use of a prospectively defined protocol. Included were 19 768 patients, 102 559 person-years of follow-up, 2194 primary end points (coronary death or nonfatal myocardial infarction), and 3717 expanded end points (primary end point, CABG, or PTCA). Pravastatin significantly reduced relative risk in younger (<65 years) and older (>/=65 years) patients, men and women, smokers and nonsmokers, and patients with or without diabetes or hypertension. The relative effect was smaller, but absolute risk reduction was similar in patients with hypertension compared with those without hypertension. Relative risk reduction was significant in predefined categories of baseline lipid concentrations. Tests for interaction were not significant between relative risk reduction and baseline total cholesterol (5% to 95% range 177 to 297 mg/dL, 4.6 to 7.7 mmol/L), HDL cholesterol (27 to 58 mg/dL, 0.7 to 1.5 mmol/L), and triglyceride (74 to 302 mg/dL, 0.8 to 3.4 mmol/L) concentrations, analyzed as continuous variables. However, for LDL cholesterol, the probability values for interaction were 0.068 for the prespecified primary end point and 0.019 for the expanded end point. Relative risk reduction was similar throughout most of the baseline LDL cholesterol range (125 to 212 mg/dL, 3.2 to 5.5 mmol/L) with the possible exception of the lowest quintile of CARE/LIPID (<125 mg/dL) (relative risk reduction 5%, 95% CI 19% to -12%).

CONCLUSIONS

Pravastatin treatment is effective in reducing coronary heart disease events in patients with high or low risk factor status and across a wide range of pretreatment lipid concentrations.

Effects of lovastatin and pravastatin on the survival of hamsters with inherited cardiomyopathy

Cardiomyopathic hamsters develop heart disease early in life, which leads to congestive heart failure and death as these hamsters age. Hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been reported to reduce ubiquinone concentrations and to deteriorate myocardial function in humans and in experimental animals. HMG-CoA reductase inhibitors differ regarding their ability to penetrate extrahepatic tissues. As a consequence, lovastatin inhibits cholesterol biosynthesis at least 100-fold more effectively than pravastatin in extrahepatic cells. We examined the effect of lovastatin and pravastatin (approximately 10 mg per kilogram of body weight and per day mixed in the diet) compared with controls on the lifespan of cardiomyopathic hamsters (BIO 8262 strain) in the heart-failure period. In male hamsters, neither lovastatin nor pravastatin significantly affected survival. In female hamsters, lovastatin reduced median survival time from 89 days (control animals) to 30 days (P <.05); pravastatin (median survival, 115 days) had no statistically significant effect. We conclude that lovastatin, but not pravastatin, at a daily dose of 10 mg per kilogram of body weight significantly increases the mortality of cardiomyopathic hamsters. This effect may be the result of inhibition of myocardial ubiquinone supply.

Atorvastatin upregulates type III nitric oxide synthase in thrombocytes, decreases platelet activation, and protects from cerebral ischemia in normocholesterolemic mice

BACKGROUND AND PURPOSE

Thrombosis superimposed on atherosclerosis causes approximately two thirds of all brain infarctions. We previously demonstrated that statins protect from cerebral ischemia by upregulation of endothelial type III nitric oxide synthase (eNOS), but the downstream mechanisms have not been determined. Therefore, we investigated whether antithrombotic effects contribute to stroke protection by statins.

METHODS

129/SV wild-type and eNOS knockout mice were treated with atorvastatin for 14 days (0.5, 1, and 10 mg/kg). eNOS mRNA from aortas and platelets was measured by reverse-transcriptase polymerase chain reaction. Platelet factor 4 (PF 4) and beta-thromboglobulin (beta-TG) in the plasma were quantified by ELISA. Transient cerebral ischemia was induced by filamentous occlusion of the middle cerebral artery followed by reperfusion.

RESULTS

Stroke volume after 1-hour middle cerebral artery occlusion/23-hour reperfusion was significantly reduced by 38% in atorvastatin-treated animals (10 mg/kg) compared with controls. Serum cholesterol levels were not affected by the treatment. eNOS mRNA was significantly upregulated in a dose-dependent manner in aortas and in thrombocytes of statin-treated mice compared with controls. Moreover, indices of platelet activation in vivo, ie, plasma levels of PF 4 and beta-TG, were dose-dependently downregulated in the treatment group. Surprisingly, atorvastatin-treatment did not influence PF 4 and beta-TG levels in eNOS knockout mice.

CONCLUSIONS

The synthetic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor atorvastatin upregulates eNOS in thrombocytes, decreases platelet activation in vivo, and protects from cerebral ischemia in normocholesterolemic mice. Antithrombotic and stroke-protective effects of statins are mediated in part by eNOS upregulation. Our results suggest that statins may provide a novel prophylactic treatment strategy independent of serum cholesterol levels.

The aggressive low density lipoprotein lowering controversy

Recent clinical trials have provided unequivocal evidence of major cardiovascular benefits from low density lipoprotein (LDL) lowering with statins. However, the three critical unresolved questions about aggressive LDL lowering are the shape of the curve relating cardiac events to LDL, the best surrogate measurement for assessing therapeutic efficacy and the best target for LDL therapy. The relation between cardiac events and LDL is curvilinear, both epidemiologically and during therapy. The benefit of lipid lowering diminishes progressively and becomes difficult to detect at lower LDL levels without a very large sample size. Assessment of the benefits of lipid lowering is further confounded by differences in the level of pretreatment LDL and by the non-LDL lowering effects of statins. Both epidemiologic studies and large randomized clinical trials have produced conflicting results concerning the best LDL target. Failure to reduce the event rate in patients with pretreatment LDL <125 mg (Cholesterol And Recurrent Events [CARE] trial) alerts us to the risk of extrapolating epidemiologic data to clinical practice, yet subset analysis of some clinical trials suggests the greatest benefit appears in those patients with the lowest on-treatment LDL levels (Scandinavian Simvastatin Survival Study [4S]). This controversy should be resolved in the next few years by several important on-going trials. In the face of seemingly contradictory data from current clinical trials, we can only speculate that very aggressive LDL lowering to <80 mg/dl could be accompanied by a modest therapeutic benefit beyond the current recommendations of the National Cholesterol Education Program. If any benefit is observed, it will have to be balanced against a small potential for increased adverse events.

Serum lipid levels during and after adjuvant toremifene or tamoxifen therapy for breast cancer

Tamoxifen decreases serum cholesterol (S-cholesterol) level about 10% and low-density lipoprotein cholesterol (S-LDL) 15-20%, but in most studies it has increased serum triglyceride levels and had little effect on serum high-density cholesterol (S-HDL). The effect of another antiestrogen, toremifene, on the serum lipid profile has not been completely studied. We monitored serum lipid levels longitudinally in 141 axillary node-positive postmenopausal breast cancer patients who received randomly either 40 mg toremifene or 20 mg tamoxifen as adjuvant therapy for 36 months, and in 34 postmenopausal women who received no adjuvant systemic therapy after surgery for axillary node-negative breast cancer. No significant differences were found between the drugs in their effects on S-cholesterol, LDL, HDL, or triglyceride levels, or on the cholesterol-to-HDL or LDL-to-HDL ratios. For both drugs the S-cholesterol and S-LDL absolute lowering effect was the greater the higher the pretreatment level. For a patient with a median pretreatment value, toremifene decreased S-cholesterol 6% and tamoxifen 13%, and S-LDL decreased by 13% and 23%, respectively, at 6 months of therapy. Six months after stopping three-year antiestrogen therapy S- cholesterol and S-LDL levels had returned to the pretreatment levels. In conclusion, we found no major differences between 40 mg toremifene and 20 mg of tamoxifen in their effect on the serum lipid levels, which return to the pretreatment levels within 6 months after cessation of therapy.

Decreasing mortality with primary percutaneous coronary intervention in patients with acute myocardial infarction: the Mayo Clinic experience from 1991 through 1997

OBJECTIVE

To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI).

PATIENTS AND METHODS

We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year.

RESULTS

The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P < .001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P < .001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P < .001). An increase in beta-blocker (58.3% to 75.3%; P < .001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P < .001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P < .001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P < .001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04).

CONCLUSIONS

Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

Implications of cardiovascular risk in patients with type 2 diabetes who have abnormal lipid profiles: is lower enough?

Patients with type 2 diabetes are at high risk for coronary heart disease (CHD); frequently, these patients have abnormal lipid profiles, placing them at even greater risk. A syndrome of insulin resistance, hyperinsulinaemia, hypertension, and high levels of fibrinogen and plasminogen activator inhibitor contributes to cardiovascular risk, which is not sufficiently decreased by glycaemic control alone. In several large interventional trials, CHD risk in patients with diabetes was substantially reduced by aggressive lipid-lowering therapy. In patients with diabetes, CHD, low high-density lipoprotein levels, and normal low-density lipoprotein levels, gemfibrozil reduced fatal and non-fatal CHD events. For lipid-lowering in patients with diabetes and CHD, pravastatin and simvastatin are the only HMG-CoA reductase inhibitors shown to reduce fatal and non-fatal CHD events. Of these, pravastatin has less potential for drug-drug interactions and may be safer to use, particularly for combination therapy with fibric acid derivatives, as may now be important for CHD prevention in mixed dyslipidaemias.

Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. PREVENT Investigators

BACKGROUND

The results of angiographic studies have suggested that calcium channel-blocking agents may prevent new coronary lesion formation, the progression of minimal lesions, or both.

METHODS AND RESULTS

The Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT) was a multicenter, randomized, placebo-controlled, double-masked clinical trial designed to test whether amlodipine would slow the progression of early coronary atherosclerosis in 825 patients with angiographically documented coronary artery disease. The primary outcome was the average 36-month angiographic change in mean minimal diameters of segments with a baseline diameter stenosis of 30%. A secondary hypothesis was whether amlodipine would reduce the rate of atherosclerosis in the carotid arteries as assessed with B-mode ultrasonography, which measured intimal-medial thicknesses (IMT). The rates of clinical events were also monitored. The placebo and amlodipine groups had nearly identical average 36-month reductions in the minimal diameter: 0.084 versus 0.095 mm, respectively (P:=0.38). In contrast, amlodipine had a significant effect in slowing the 36-month progression of carotid artery atherosclerosis: the placebo group experienced a 0.033-mm increase in IMT, whereas there was a 0. 0126-mm decrease in the amlodipine group (P:=0.007). There was no treatment difference in the rates of all-cause mortality or major cardiovascular events, although amlodipine use was associated with fewer cases of unstable angina and coronary revascularization.

CONCLUSIONS

Amlodipine has no demonstrable effect on angiographic progression of coronary atherosclerosis or the risk of major cardiovascular events but is associated with fewer hospitalizations for unstable angina and revascularization.

Comparative tolerability of the HMG-CoA reductase inhibitors

The availability of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors has revolutionised the treatment of lipid abnormalities in patients at risk for the development of coronary atherosclerosis. The relatively widespread experience with HMG-CoA therapy has allowed a clear picture to emerge concerning the relative tolerability of these agents. While HMG-CoA reductase inhibitors have been shown to decrease complications from atherosclerosis and to improve total mortality, concern has been raised as to the long term safety of these agents. They came under close scrutiny in early trials because ocular complications had been seen with older inhibitors of cholesterol synthesis. However, extensive evaluation demonstrated no significant adverse alteration of ophthalmological function by the HMG-CoA reductase inhibitors. Extensive experience with the potential adverse effect of the HMG-CoA reductase inhibitors on hepatic function has accumulated. The effect on hepatic function for the various HMG-CoA reductase inhibitors is roughly dose-related and 1 to 3% of patients experience an increase in hepatic enzyme levels. The majority of liver abnormalities occur within the first 3 months of therapy and require monitoring. Rhabdomyolysis is an uncommon syndrome and occurs in approximately 0.1% of patients who receive HMG-CoA reductase inhibitor monotherapy. However, the incidence is increased when HMG-CoA reductase inhibitors are used in combination with agents that share a common metabolic path. The role of the cytochrome P450 (CYP) enzyme system in drug-drug interactions involving HMG-CoA reductase inhibitors has been extensively studied. Atorvastatin, cerivastatin, lovastatin and simvastatin are predominantly metabolised by the CYP3A4 isozyme. Fluvastatin has several metabolic pathways which involve the CYP enzyme system. Pravastatin is not significantly metabolised by this enzyme and thus has theoretical advantage in combination therapy. The major interactions with HMG-CoA reductase inhibitors in combination therapy involving rhabdomyolysis include fibric acid derivatives, erythromycin, cyclosporin and fluconazole. Additional concern has been raised relative to overzealous lowering of cholesterol which could occur due to the potency of therapy with these agents. Currently, there is no evidence from clinical trials of an increase in cardiovascular or total mortality associated with potent low density lipoprotein reduction. However, a threshold effect had been inferred by retrospective analysis of the Cholesterol and Recurrent Events study utilising pravastatin and the role of aggressive lipid therapy is currently being addressed in several large scale trials.

Pharmacotherapy following myocardial infarction--a review of current treatment practices

Modern treatment of acute myocardial infarction (AMI), including thrombolysis and early interventional strategies, has reduced mortality rates but increased the number of patients requiring medical treatment. Post infarction treatment with aspirin, statins, beta-blockers and angiotensin-converting enzyme (ACE) inhibitors has improved morbidity and mortality and is cost-effective. The major successes of secondary prevention have been seen in the prevention of reinfarction, recurrent ischaemia and the development of heart failure. However, in spite of recent advances and increasing knowledge, the mortality rates remain high, partly due to the under use of the established and documented medical strategies. Implementation of the current treatment strategies into general practice remains a challenge. The field is undergoing rapid change due to the increasing use of early invasive strategies. The primary objective should remain the prevention of underlying aetiology: coronary artery disease (CAD). Secondary prevention following myocardial infarction (MI) will remain a major challenge in clinical practice within the foreseeable future.

Global risk assessment for lipid therapy to prevent coronary heart disease

Randomized clinical trials have established that lipid- lowering pharmacologic therapy can substantially reduce morbidity and mortality in patients with known coronary artery disease (CAD). Researchers are now working to define the role of lipid-lowering agents in the primary prevention of CAD to extend their benefit to patients at increased risk for future coronary events. The risk assessment models presently used for secondary prevention are not sufficient to identify high-risk, asymptomatic patients. Building on the accumulated data about the physiologic mechanisms and metabolic factors that contribute to CAD, novel serum markers and diagnostic tests are being critically studied to gauge their utility for the assessment of high-risk patients and occult vascular disease. New risk prediction models that combine traditional risk factors for CAD with the prudent use of new screening methods will allow clinicians to target proven risk reduction therapies at high-risk patients before they experience a cardiac event.

Implications of the atorvastatin versus revascularization treatment (AVERT) study for the clinician

The underlying disorder in the vast majority of cases of cardiovascular disease is atherosclerosis, for which low-density lipoprotein cholesterol is recognized as a major risk factor. Data from epidemiologic studies have suggested that lower cholesterol levels are associated with a lower overall risk of morbidity and mortality due to coronary heart disease. Numerous clinical trials with lipid-lowering agents support these epidemiologic data. Of these, studies with the HMG-CoA (3-hydroxy 3-methylglutaryl coenzyme A) reductase inhibitors, or statins, have shown the greatest lipid-lowering effects. Data from recent trials such as the Atorvastatin Versus Revascularization Treatment contribute to a growing body of evidence that suggests that aggressive reduction of cholesterol can yield additional clinical benefits above and beyond that observed with less robust treatment regimens. Aggressive cholesterol-lowering strategies have the potential therefore to have a significant impact on levels of atherosclerotic disease throughout the westernized world. Such effects argue in favor of renaming the entire class of drugs as anti- atherosclerotic rather than lipid-lowering agents.

The benefit of aggressive lipid lowering

The beneficial effects of lipid-lowering therapy for the primary and secondary prevention of coronary heart disease (CHD) have been conclusively demonstrated in large-scale clinical trials. Does more aggressive lipid lowering provide even greater clinical benefit? The post coronary artery bypass graft (post-CABG) study was the first angiographic trial to show that aggressive lipid-lowering therapy was more effective at reducing disease progression than conventional approaches to cholesterol management. Recently, the results of the atorvastatin versus revascularization treatments (AVERT) trial have also shown significant benefit on clinical events with aggressive lipid lowering. A total of 341 patients with stable CHD were randomly assigned to receive medical therapy with atorvastatin 80 mg/day plus conventional treatment or angioplasty followed by usual care. Atorvastatin therapy resulted in a 46% reduction in the mean low-density lipoprotein cholesterol level compared with an 18% decrease for patients in the angioplasty/usual care group. Patients treated with atorvastatin had fewer ischemic events compared with those who had angioplasty (13 vs. 21%, P = 0.048) and a significantly greater time to first ischemic event (P = 0.027). AVERT is the first clinical study demonstrating that patients with stable CHD achieve significant cardiovascular benefit by aggressively lowering cholesterol levels with atorvastatin. It would therefore appear that an aggressive approach to lipid-lowering therapy is beneficial in patients with existing CHD.

[Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention]

The document "Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention" reviews the current evidence on cardiovascular disease prevention and the therapeutic advances achieved in recent years, in order to aid risk-based clinical decision-making. Cardiovascular diseases rank as the first cause of death in Spain. Their demographic, health and social impact is increasing and it is likely to continue to do so in the next decades. Appropriate treatment for high blood cholesterol and other major risk factors is crucial in cardiovascular disease prevention. Individual risk stratification is essential to determine follow-up periodicity and treatment. Priorities for the control of cholesterolemia and the consequent cardiovascular risk are based on risk stratification. In primary prevention, the therapeutic objective in high risk patients has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol > or = 130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. In moderate-severe hypertriglyceridemia or low HDL-cholesterol, fibrates are preferred. In acute coronary syndrome, hypolipemiant treatment, should be started as soon as possible, when indicated. Secondary prevention programmes that continually provide good clinical and risk factor control should be provided to coronary heart disease patients.

Identifying patients at risk for coronary heart disease: implications from trials of lipid-lowering drug therapy

Abnormal lipid levels contribute significantly to the risk of coronary heart disease (CHD), which is increased further in the presence of other risk factors. The association between elevated low-density lipoprotein (LDL) cholesterol and CHD risk is well established, and large primary and secondary prevention studies of HMG-CoA reductase inhibitors (statins) have shown conclusively that lowering LDL cholesterol levels reduces CHD events and total mortality. Regardless of the intervention used (diet, surgery, drugs), reduction of plasma cholesterol has consistently produced a reduction in cardiovascular risk. Absolute benefit is greatest in those who are at highest risk initially, and trial results suggest that the lower the LDL cholesterol level achieved, at least down to LDL of 3.0 mmol/l, then the lower is the CHD event risk. Epidemiological data also point to the negative impact of other lipids on CHD risk. Low levels of high-density lipoprotein (HDL) and high levels of triglycerides (particularly in conjunction with an LDL/HDL ratio >5) are particularly strong risk factors for CHD. Thus, although prevention trials to date have primarily assessed the impact of LDL lowering on CHD events, the initial assessment of CHD risk should consider a more detailed atherogenic profile including HDL and triglyceride levels. A general approach to preventing cardiovascular disease should include strategies to reduce the overall CHD risk by lifestyle modification and management of modifiable risk factors such as smoking, hypertension and diabetes. Based on data from recent prevention studies, and because they are the most potent lipid-lowering agents available for lowering LDL cholesterol, statins have appropriately become the drug of choice for most patients with hyperlipidaemia who require drug therapy.

Safety and efficacy of HMG-CoA reductase inhibitors for treatment of hyperlipidemia in patients with HIV infection

STUDY OBJECTIVE

To assess the efficacy and safety of HMG-CoA reductase inhibitors (statins) in patients with human immunodeficiency virus (HIV) infection and hyperlipidemia.

DESIGN

Retrospective analysis.

SETTING

HIV clinic.

PATIENTS

Twenty-six HIV-infected patients with hyperlipidemia.

INTERVENTION

Five patients received pravastatin, 13 lovastatin, 10 simvastatin, and 2 atorvastatin (total 30 courses).

MEASUREMENTS AND MAIN RESULTS

Reductions in cholesterol and triglycetides were used to assess efficacy; creatine kinase (CK), liver enzymes, and myalgia were markers of statin toxicity. After a median of 8.2 and 7.2 months of treatment, the agents collectively reduced median baseline total cholesterol 27% (354 to 263 mg/dl) and triglycerides 15% (513 to 438 mg/dl), respectively. Two patients, one with marked CK elevations, experienced myalgias with lovastatin, and two experienced transaminase elevations 3 or more times the upper limit of normal.

CONCLUSION

Statins are effective in reducing total cholesterol and triglycerides in HIV-infected patients, although lipid levels infrequently return to normal. Lovastatin should be avoided in patients receiving concomitant drugs that may potentiate skeletal muscle toxicity with this agent.

Lipid lowering drugs and recurrences of life-threatening ventricular arrhythmias in high-risk patients

OBJECTIVES

To evaluate a possible effect of lipid lowering drugs on recurrences of ventricular arrhythmias (VA) after implantable cardioverter defibrillator (ICD) implantation.

BACKGROUND

In patients with coronary artery disease (CAD), lipid lowering drugs reduce total and sudden cardiac death. Because the mechanism is not completely understood, we studied whether these drugs have a favorable influence on the occurrence of life-threatening VA in patients with CAD and ICD implants.

METHODS

We conducted an observational study in 78 patients with CAD and life-threatening VA, treated with an ICD. After ICD implantation, 27 patients were on treatment with lipid lowering drugs (group I) and 51 were not (group II). Patients were studied for the following end points: recurrences of VA requiring ICD intervention, cardiac death and hospitalization.

RESULTS

After a mean follow-up of 490 +/- 319 days, 35 patients (45%) had recurrences of VA requiring ICD intervention. In multivariate analysis, the use of lipid lowering drugs (chi-square 6.33, p = 0.012) and poorly tolerated sustained monomorphic ventricular tachycardia as initial presentation (chi-square 4.84, p = 0.028) remained as independent predictors of recurrences of VA. Patients in groups I and II had similar baseline clinical characteristics, but patients in group I had a lower incidence of recurrences of VA (6/27 or 22% vs. 29/51 or 57%, p = 0.004) and of the combined end points of cardiac death and hospitalization (4/27 or 15% vs. 23/51 or 45%, p = 0.015) compared with patients in group II.

CONCLUSIONS

This is the first observation that the use of lipid lowering drugs is associated with a reduction of recurrences of VA in patients with CAD and ICD implants. These data require confirmation in a prospective randomized trial.

The role of fibric acid derivatives in the secondary prevention of coronary heart disease

Fibric acid derivatives effectively lower triglycerides and raise high-density lipoprotein (HDL) cholesterol, but their effect on low-density lipoprotein (LDL) cholesterol is weakly beneficial (small decreases) to adverse (small increases) and varies according to the triglyceride level. Early primary prevention studies of atherosclerosis using the fibric acid derivative clofibrate showed only modest effects on atherosclerosis and an alarming increase in mortality in the intervention group. Although the Helsinki Heart Study later demonstrated that gemfibrozil decreased cardiac endpoints in primary prevention without increasing total mortality, the efficacy of fibric acid derivatives in both primary and secondary prevention of atherosclerosis has remained widely in doubt. Nevertheless, many patients with atherosclerosis have normal or even low LDL cholesterol, but elevated triglyceride, and low HDL cholesterol; furthermore, even aggressive LDL cholesterol lowering with HMG Co-A (3-hydroxy 3-methylglutaryl coenzyme A) reductase inhibitors (statins) fails to prevent the majority of atherosclerotic events. These findings have kindled increased interest in the use of fibric acid derivatives in atherosclerosis prevention, especially through treatment of non-LDL dyslipidemias. Recent studies with angiographic and clinical end-points have now provided evidence for a beneficial effect of at least some drugs in this class in the secondary prevention of atherosclerosis.

The revised joint guidelines

There is a wealth of scientific evidence that lifestyle interventions and the use of drug therapies in patients with coronary heart disease (CHD) and individuals at high risk for developing CHD can reduce cardiovascular morbidity and mortality. In the revised guidelines of the European Joint Task Force for the prevention of CHD in clinical practice, these individuals remain the priority for prevention. The new guidelines have been formulated as a result of evidence from numerous epidemiological, observational and clinical trials and define specific goals of therapy for the management of lipids, blood pressure and diabetes. The intensity of lifestyle intervention and need for drug therapy should be determined by the absolute risk of a major ischemic event, based on an assessment of all risk factors. Implementation of these recommendations in clinical practice will ensure a common approach to CHD prevention throughout Europe and improve patients' quality of life.

Diet as preventive medicine in cardiology

Because the main cause of death in patients with established coronary heart disease (CHD) is sudden cardiac death (SCD), physicians should develop specific strategy, including dietary changes, to prevent it. In the long term, reduction of the diet-dependent chronic risk factors of CHD, hypercholesterolemia, hypertension, and diabetes, is also important. The association of the cardioprotective effects of the Mediterranean diet (through various mechanisms, likely including the prevention of SCD) with those expected from the reduction of blood lipids and blood pressure and a better control of diabetes (in addition to its gastronomic appeal) renders this dietary pattern extremely attractive for public health purposes. Experimental and epidemiologic studies, as well as randomized trials, clearly demonstrated that n-3 fatty acids reduce the risk of SCD in CHD patients. Their use is now encouraged either as supplements or as part of a Mediterranean-type diet.

Treating to target with statins

Large-scale drug intervention trials have proven that cholesterol-lowering therapy reduces the risk of coronary events in a wide range of at-risk patient groups. This has led to a growing consensus that plasma total and low-density lipoprotein cholesterol (LDL-C) should be reduced to target levels that have been shown in population studies to be associated with low rates of coronary heart disease (CHD). Despite this consensus, however, a substantial proportion of patients at high coronary risk still do not receive lipid-lowering therapy. Furthermore, of those patients receiving therapy, many do not achieve the recommended targets. In order to address this problem, several treatment-to-target studies have been conducted to determine whether recommended targets are attainable with the lipid-lowering drugs that are currently available. These studies have confirmed that the statins are able to achieve recommended target levels in the majority of patients at risk. The studies have also demonstrated that most patients achieve a total cholesterol target with atorvastatin.

Cholesterol lowering in atherosclerosis

Lipid-lowering with statins reduces disease progression, prevents myocardial infarction and other hard end points, and prolongs survival. Data from large-scale trials with these agents further show that lowering low-density lipoprotein (LDL) cholesterol in patients with coronary artery disease reduces the incidence of cardiovascular events and that the lower the LDL cholesterol achieved, the lower the event rate. Currently available evidence supports the National Cholesterol Education Program (NCEP) recommendations for reduction of LDL-cholesterol levels to at least 100 mg/dL in patients with coronary artery disease. The Treating to New Targets study, which will evaluate the effects of LDL-cholesterol lowering to < or = 75 mg/dL with atorvastatin, may help clarify if additional benefit accrues with further reductions. However, up to 82% of patients with proven coronary disease are not even at the current NCEP lipid goal. Up to 55% need a > 30-mg/dL reduction in LDL cholesterol to reach that goal. These data suggest that many patients are not receiving a statin or are receiving an inadequate dose. Aggressive lipid lowering, although a desirable goal, does not yet appear to be standard practice.

Effect of cholesterol-lowering therapy on coronary endothelial vasomotor function in patients with coronary artery disease

BACKGROUND

Improved endothelial function may contribute to the beneficial effects of cholesterol-lowering therapy.

METHODS AND RESULTS

In this randomized, double-blind study, we compared the effect of 6 months of simvastatin (40 mg/d) treatment with that of placebo on coronary endothelial vasomotor function in 60 patients with coronary artery disease. Simvastatin lowered LDL-cholesterol by 40+/-12% from 130+/-28 mg/dL (P<0.001). Peak intracoronary acetylcholine infusion produced epicardial coronary constriction at baseline in both the simvastatin (-17+/-13%) and placebo (-24+/-16%) groups. After treatment, acetylcholine produced less constriction in both groups (-12+/-19% and -15+/-14%, respectively, P=0.97). The increase in coronary blood flow during infusion of the peak dose of substance P was blunted at baseline in both the simvastatin (42+/-50%) and placebo (55+/-71%) groups, reflecting impaired endothelium-dependent dilation of coronary microvessels. After treatment, the flow increase was 82+/-81% in the simvastatin group and 63+/-53% in the placebo group (P=0.16).

CONCLUSIONS

Six months of cholesterol-lowering therapy has no significant effect on coronary endothelial vasomotor function in the study population of patients with coronary artery disease and mildly elevated cholesterol levels. These findings suggest that the effects of cholesterol lowering on endothelial function are more complex than previously thought.

Pravastatin therapy and the risk of stroke

BACKGROUND

Several epidemiologic studies have concluded that there is no relation between total cholesterol levels and the risk of stroke. In some studies that classified strokes according to cause, there was an association between increasing cholesterol levels and the risk of ischemic stroke and a possible association between low cholesterol levels and the risk of hemorrhagic stroke. Recent reviews of trials of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors have suggested that these agents may reduce the risk of stroke.

METHODS

In a double-blind trial (the Long-Term Intervention with Pravastatin in Ischaemic Disease study), we compared the effects of pravastatin on mortality due to coronary heart disease (the primary end point) with the effects of placebo among 9014 patients with a history of myocardial infarction or unstable angina and a total cholesterol level of 155 to 271 mg per deciliter (4.0 to 7.0 mmol per liter). Our goal in the present study was to assess effects on stroke from any cause and nonhemorrhagic stroke, which were secondary end points.

RESULTS

There were 419 strokes among 373 patients over a follow-up period of six years. A total of 309 strokes were classified as ischemic, 31 as hemorrhagic, and 79 as of unknown type. Among the patients given placebo, the risk of stroke was 4.5 percent, as compared with 3.7 percent among those given pravastatin (relative reduction in risk, 19 percent; 95 percent confidence interval, 0 to 34 percent; P=0.05). Non-hemorrhagic stroke occurred in 4.4 percent of the patients given placebo, as compared with 3.4 percent of those given pravastatin (reduction in risk, 23 percent; 95 percent confidence interval, 5 to 38 percent; P=0.02). Pravastatin had no effect on hemorrhagic stroke (incidence, 0.2 percent in the placebo group vs. 0.4 percent in the pravastatin group; P=0.28).

CONCLUSIONS

Pravastatin has a moderate effect in reducing the risk of stroke from any cause and the risk of nonhemorrhagic stroke in patients with previous myocardial infarction or unstable angina.

Cardiac rehabilitation and secondary prevention programs for elderly cardiac patients

The utility of cardiac rehabilitation for elderly cardiac patients is controversial, and cost, logistic barriers, and encumbering comorbidities often seem disproportionate. Many clinicians view the emphasis of cardiac rehabilitation on behavior modification and risk-factor reduction as irrelevant for very old adults and consider pure exercise programs as appropriate alternatives. The strong rationale for cardiac rehabilitation and secondary prevention is elucidated, and available corroborating data are presented. The benefits of exercise prescription in cardiac rehabilitation and synchronized risk-factor reduction are pertinent to aging and age-related heart disease, including coronary heart disease and heart failure.

Cost-effectiveness of statins

The efficacy of lipid-lowering with statins has become clear. Indirect estimations, and direct measurements from long-term randomized trials have also demonstrated cost-effectiveness, both in secondary and primary prevention of coronary heart disease. Targeting care efficiently to high-risk groups by calculating absolute risk is essential. However, it is clear that what would normally be very cost-effective interventions will put substantial strain on health care resources because of the common nature of coronary disease and risk factors.

Debate: at what level of coronary heart disease risk should a statin be prescribed?

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are effective treatments for the primary and secondary prevention of coronary heart disease, but an outstanding issue is determining who should have such treatment. The benefit from treatment with statins appears to be proportional to the underlying risk of coronary heart disease and independent of the factors increasing risk. Most benefit will therefore be achieved by treating people at increased risk of coronary heart disease. Statins reduce coronary morbidity even when the risk of coronary heart disease is relatively low (6% over 10 years), but reduction in all-cause mortality, the true measure of safety has been shown only when the risk of a major coronary heart disease event is 15% over 10 years or greater. At this level of risk patients appear willing to take treatment to gain the benefit expected from statin treatment, and the cost effectiveness of statin treatment is within the range accepted for other treatments. The major impediments to the systematic introduction of statin treatment at this level of risk are the very high overall cost and the large workload in countries like Britain, where the population risk of coronary heart disease is high. For this reason, recent British guidelines correctly advise statin treatment for secondary prevention and primary prevention when the 10 year coronary heart disease risk is 30% or greater as the first priority, moving to a lower coronary heart disease threshold for primary prevention only when resources permit.

At what level of coronary heart disease risk should a statin be prescribed?

Statin therapy has been conclusively shown to offer patients clinical benefit, virtually irrespective of their baseline risk status. However, the absolute risk reductions observed in different clinical trials, which have recruited patients across a spectrum of lipid levels and vascular disease states, show that baseline global risk determines the absolute benefit gained and in turn will specify the number of patients needed to be treated in order to realize this benefit. Global risk assessment is therefore central to the clinically meaningful use of statin therapy, and a strong case is now argued in the literature for a high-risk primary prevention strategy that goes hand in hand with standard secondary prevention. The routine use of Framingham-based risk assessment tools is advocated because these are the most widely evaluated and have been repeatedly shown to predict the risk of coronary heart disease accurately in western populations. The risk threshold in primary prevention that should determine pharmacological intervention is the subject of controversy. The currently used annual risk figure of 3% would clearly capture all very high-risk individuals but would also deny treatment to many individuals who will subsequently die from their first coronary event. Although a 1.5% annual risk threshold is economically untenable in the present UK health system, a level of 2% is, we believe, both achievable and affordable.

Simvastatin inhibits the monocyte expression of proinflammatory cytokines in patients with hypercholesterolemia

OBJECTIVE

The purpose of this study was to assess if simvastatin has an anti-inflammatory activity in patients with hypercholesterolemia.

BACKGROUND

Simvastatin, an inhibitor of 3-hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) reductase, reduced cardiovascular events in patients with myocardial infarction and hypercholesterolemia.

METHODS

Sixteen patients with polygenic hypercholesterolemia were randomly allocated to diet (n = 8) or diet plus 20 mg/day simvastatin (n = 8) for eight weeks. Before and at the end of treatment period, lipid profile and monocyte expression of tumor necrosis factor-alpha (TNF) and interleukin-1beta (IL-1beta) were measured.

RESULTS

At baseline no difference in lipid profile and monocyte expression of TNF and IL-1beta were observed between the two groups. In patients allocated to diet alone, no change in lipid profile and monocyte expression of TNF and IL-1beta was seen. In patients with diet plus simvastatin, significant decreases of total cholesterol (-27%, p<0.02), low density lipoprotein-cholesterol (-33%, p<0.02), and monocyte expression of TNF (-49%, p<0.02) and IL-1beta (-35%, p<0.02) were observed. At the end of treatment period, patients treated with simvastatin had lower cholesterol and monocyte TNF and IL-1beta than did patients assigned to diet alone.

CONCLUSION

This study suggests that simvastatin possesses anti-inflammatory activity via the inhibition of pro-inflammatory cytokines TNF and IL-1beta expressed by monocytes.

Management of coronary artery disease: therapeutic options in patients with diabetes

OBJECTIVES

The aim of this review is to discuss the particularities of coronary artery disease (CAD), the effect of intensive medical management and the outcome of percutaneous and surgical revascularization in patients with diabetes mellitus (DM).

BACKGROUND

CAD represents the leading cause of death in patients with DM. Numerous clinical, biological and angiographic risk factors have been shown to be associated with CAD in diabetic patients.

METHODS

Metabolic abnormalities in patients with DM including insulin resistance, hyperglycemia and dyslipidemia are briefly discussed. Then the potential roles of medical management and of percutaneous and surgical coronary revascularization are more extensively reviewed.

RESULTS

More vigorous control of hyperglycemia, hyperlipidemia, hypertension and other risk factors may be of crucial importance for risk reduction. Despite remarkable progress in recent years, the choice of a coronary revascularization strategy remains a challenge in these patients. Diabetic patients with CAD are predisposed to higher cardiovascular events after balloon angioplasty. Whether stenting and new antiplatelet drugs improve the results of percutaneous revascularization in this population needs further evaluation. The superiority of the surgical approach is also not definitely established. Therefore, many aspects of coronary revascularization are still unclear in these patients.

CONCLUSIONS

The results of ongoing randomized trials comparing multiple coronary stents to bypass surgery will likely provide some answers to our questions and additional randomized trials evaluating intensive diabetic control with or without coronary revascularization are needed to determine the best therapeutic approach in these patients.

Opportunistic Discovery of Occult Disease by Use of Test Panels in New, Symptomatic Primary Care Outpatients: Yield and Cost of Case Finding

Background: Diagnostic test panels have been advocated by the Japan Society of Clinical Pathology for evaluation of presenting complaints of new outpatients in primary care medicine. The tests have additional potential utility for opportunistic finding of asymptomatic diseases, but data are lacking on the number of new conditions identified by the test panels and on the cost per identified case.

Methods: We studied 540 new, symptomatic patients at the Comprehensive Medicine Clinics of National Defense Medical College during 1991–1997. All underwent testing with the “Essential Laboratory Tests” panel (2) [ELT(2) panel]. This panel includes hematologic tests, urinalysis, total protein, C-reactive protein, albumin, cholesterol, triglycerides, glucose, urea nitrogen, creatinine, uric acid, serum protein fractionation, six enzymes, and optional tests, including x-rays, electrocardiogram, and fecal occult blood.

Results: The ELT(2) panel uncovered 276 additional diagnoses of asymptomatic disease or abnormal health status. The most frequent occult condition was hyperlipidemia (100 cases) followed by liver dysfunction (53 cases). Clinical efficiency of the panel (occult diseases/patient) varied depending on the category of tentative initial diagnosis, with the highest efficiency in patients with cardiovascular disease. We created smaller panels by combining 11 basic tests [called the ELT(1) baseline panel] with one or more additional tests from the ELT(2) and analyzed their cost-effectiveness. Addition of four tests (total cholesterol, alanine aminotransferase, glucose, and uric acid) improved both clinical efficiency (0.41 occult disease/patient) and economic efficiency [¥2372 (∼$22.50 US)/occult disease] at a cost-effectiveness of ¥177 per incremental case of occult disease. Addition of further tests decreased cost-effectiveness.

Conclusions: Although the ELT(2) panel has supplemental utility for opportunistic screening of some significant, occult diseases and conditions, universal utilization of the full panel is not supported by the cost-effectiveness found in this study.

Benefits of early lipid-lowering intervention in high-risk patients: the lipid intervention strategies for coronary patients study

BACKGROUND

There is controversy about whether lipid-lowering pharmacotherapy should be initiated immediately after an acute coronary event or only after diet and lifestyle changes have proved inadequate.

OBJECTIVE

This study, known as the Lipid Intervention Strategies for Coronary Patients Study, compared the efficacy of immediate versus deferred simvastatin treatment in conjunction with dietary advice about reducing lipid levels in hypercholesterolemic patients with acute coronary syndromes.

METHODS

This randomized, open-label, parallel-group study included 151 hypercholesterolemic (low-density lipoprotein cholesterol [LDL-C] >3.0 mmol/L) men and women aged 35 to 75 years. Within 4 days of diagnosis of acute myocardial infarction (MI) or unstable angina pectoris, all patients received dietary advice from a specially trained nurse. Subsequently, patients were randomized to 2 treatment groups: 1 group received immediate treatment with simvastatin 40 mg/d; patients in the other group received simvastatin 40 mg/d after 3 months only if their LDL-C remained >3.0 mmol/L.

RESULTS

The immediate-simvastatin group (n = 73) and the deferred-simvastatin group (n = 78) were balanced with respect to baseline characteristics. Of the 151 patients, 25% were women, 25% had concomitant hypertension, and 75% had a diagnosis of MI on enrollment. At 3 months, 90% of the patients receiving dietary advice plus immediate simvastatin treatment had achieved the recommended European target LDL-C level of <3.0 mmol/L, compared with 7% of those treated with diet alone. By 6 months, when 92% of the study participants were receiving simvastatin 40 mg/d, the proportion of patients achieving target LDL-C levels was 92% in the group that received immediate simvastatin therapy and 81% in the group that received deferred simvastatin therapy. The reductions in LDL-C (42%-48%) were considered to be clinically comparable between the 2 groups at 12 months.

CONCLUSIONS

On the basis of these results, we concluded that few patients with hypercholesterolemia and acute coronary syndromes reach the recommended European target LDL-C level of <3.0 mmol/L with dietary advice alone. However, early treatment with simvastatin 40 mg/d combined with dietary advice and follow-up at a dedicated outpatient clinic specializing in coronary heart disease resulted in 9 out of 10 patients reaching a recommended target LDL-C level of <3.0 mmol/L. Initiation of simvastatin therapy while a patient is hospitalized may increase the likelihood of the patient's lipid levels being managed according to current recommendations after he or she is discharged.