Early Use and Continuance of Statins in AMI Patients

[mmalach]

Welcome to a new cardiac clinical dialogue!

In 2005, there is no doubt about the necessity of early immediate need for statins in patients with the acute coronary syndrome (ACS) which includes: AMI, non-ST MI, and unstable angina. Therefore, the early use of statins should be added to the early use of aspirin and beta-blockers.

The MIRACL (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11277825), ESTABLISH (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15326073), and the SWEDISH REGISTRY (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11242427) studies evidence 30-day, 6-month, and 1-year reduction of coronary events and death. The pleotropic benefits of statins on morbidity and mortality of both coronary disease and stroke are shown in patients with normal cholesterol levels in the CARE (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9841599) and the AFCAPS/TexCAPS (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9613910) studies.

Unfortunately two studies published in JAMA (2002, Benner (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12132975); Jackevicius (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12132976)) report up to 50% dropout rate of continuing statins after one year in patients age 65 or older. Cost should be a much lesser factor with the availability of generic statins.

Please share you thoughts and any successful remedies by posting a reply to this message (http://jeny.ipro.org/showthread.php?p=694#post694). Please note: In order to post a message on the JENY Discussion Board, registration is necessary (http://jeny.ipro.org/register.php?). Technical assistance in registering or posting on JENY can be obtained from Linda Sheils at (516) 326-7767, ext. 324, or Scott Crespy at (516) 326-7767, ext. 252.


Monte Malach, M.D., FACC, MACP
Medical Officer IPRO
(516) 326-7767, ext. 352

[Marguerite]

Are some statins better than others. I have two friends in their fifties who stopped taking their statins due to elevated liver enzymes.

[mmalach]

According to the guidelines,in the absence of active liver disease, liver enzyme elevations up to 3times normal are not a reason to DC medication. This means that it does not rise further. It usually returns to normal. There is indication to use statins in patients with an acute coronary event even in the presence of a normal cholesterol levels. Fifty percent of AMI patients are reported to have normal cholesterol levels. I invite further comments.

[goldsteinc]

We have a population of patients who, at their initial presentation, go directly to bypass surgery. Our physicians are reluctant to initiate statins at that time, since liver enzymes may be transiently elevated post-op. Is there literature to sugest that this is a valid concern? If so, what time frame would be appropriate to initiate a statin?

[mmalach]

I am not aware of any reported concern about post cardiac surgery liver dysfunction in the absence of previously known abnormal liver tests. Therefore, there is no reason to withhold statins especially since there are reported better results after CABG and PCI in patients who are on statins (The Post Coronary Artery Bypass Graft Trial Investigators (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8992351); Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12076217)).