Starting Statins Soon After Acute Coronary Syndrome Leads to Less Unstable Angina

It has been 27 years since the FDA approved the first statin. Although the overall consensus is that this class of drugs prevents cardiovascular events and reduces mortality in patients at risk for cardiovascular disease, researchers continue to examine several questions surrounding HMG-CoA reductase inhibitors, including:

• Which patients are the best candidates for statins?
• Why do side effects occur with statin use and how can they be prevented?
• What factors affect statin adherence?
• At what age should statins be discontinued?

In a recent review article, the Cochrane Collaboration’s Heart Group addressed another persistent question: why are acute coronary syndrome (ACS) patients at elevated risk for recurrent events and death in the first 4 months?

Most studies had initiated statin therapy weeks to months following the primary ACS event, thus failing to provide evidence of early benefit. In contrast, this update of a similar review published in 2011 attempted to clarify the short-term effects of early statin use as secondary prophylaxis in ACS patients.

Of note, the authors relied on the same studies employed in the 2011 review because no additional randomized controlled trials met their inclusion criteria, which was comprised of comparing statins with placebo or usual care, starting statin therapy within 14 days of the initial ACS episode, following patients for at least 30 days, and analyzing data for at least 1 clinical outcome.

In total, the review included 18 studies involving 14,303 patients. Concerns about risk of bias and imprecision of summary estimates led the authors to designate all evidence as moderate in quality.

At both 1 month and 4 months, early statin therapy had no effect on the combined primary outcome of death, nonfatal myocardial infarction, and stroke. Additionally, early statin use did not significantly reduce risk of total death, total myocardial infarction, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at 1 month or at 4 months.

Although there were no significant risk reductions, the authors indicated favorable, non-significant trends related to statin use. For instance, patients who received statins soon after ACS were 24% less likely to experience unstable angina after 4 months.

Serious side effects occurred only rarely in the studies. Among the 14,303 patients examined, only 9 of those treated with statins developed myopathy, defined as elevated creatinine kinase levels 10 times above the upper limit of normal, compared to 1 patient in the control groups. Serious muscle toxicity was most likely to occur among those treated with simvastatin 80 mg, the authors found.