Early statin therapy in patients with acute coronary syndrome.

P atients who survive an acute coronary syndrome (ACS; myocardial infarction [MI] or unstable angina) are at a high risk of recurrent events. In this context, recent data from observational, as well as from randomised clinical trials, support an early benefit from statins started during hospital admission for an ACS in addition to improving long-term compliance with statin therapy. The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study addressed the question whether early initiation of treatment with atorvastatin reduced the occurrence of major cardiovascular events (death, nonfatal acute MI, cardiac arrest with resuscitation or recurrent myocardial ischaemia requiring emergency rehospitalisation) in patients with ACS. Adults (n=3086) admitted for an ACS were randomly assigned to atorvastatin 80 mg/d or placebo 24 to 96 h after an ACS and were followed-up for 16 weeks. Treatment with atorvastatin reduced the incidence of recurrent myocardial ischaemia requiring emergency rehospitalisation in the first 16 weeks compared to placebo (6.2% vs. 8.4%, p=0.02), but there were no significant differences between the two groups in the incidence of death, nonfatal acute MI or cardiac arrest with resuscitation. In the Pravastatin in Acute Coronary Treatment (PACT) trial, 3408 patients with an ACS were randomly assigned to 4 weeks’ treatment with pravastatin (20 to 40 mg/day) or matching placebo within 24 h after the onset of symptoms. Pravastatin treatment resulted in a non-significant decrease (6.4%) in the incidence of the primary endpoint (a composite of death, recurrence of MI or readmission to hospital for unstable angina within 30 days of randomisation) compared to placebo. In the Lipid-Coronary Artery Disease (L-CAD) study, patients were randomised, 6 days after an acute MI and/or percutaneous transluminal coronary angioplasty (PTCA) secondary to unstable angina, to either pravastatin (combined, when necessary, with cholestyramine and/or nicotinic acid) to achieve low density lipoprotein cholesterol (LDL-C) levels of ≤130 mg/dl (n=70), or to antilipidaemic therapy determined by their family physicians (n=56). After 2 years, significantly fewer patients (odds ratio 0.28, p=0.005) in the pravastatin group experienced a clinical endpoint (total mortality, cardiovascular death, nonfatal MI, need for coronary intervention, stroke and new onset of peripheral arterial disease) compared to the control group. Furthermore, minimal lumen diameter assessed by quantitative coronary angioplasty decreased by 0.18 ± 0.28 mm in the pravastatin group, whereas it increased by 0.13 ± 0.29 mm in the control group, p<0.001). The LDL levels in the pravastatin and conEarly Statin Therapy in Patients with Acute Coronary Syndrome