Statins After ACS: Continue Therapy for at Least 5 Years

Patients continue to benefit from high-dose atorvastatin therapy for at least 5 years after acute coronary syndrome, according to a new study.

Acute coronary syndrome (ACS) occurs in several forms including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA). ACS is the precursor to myocardial infarction (MI). Experts estimate that an American has an MI every 34 seconds, and 2200 Americans die from cardiovascular disease (CVD) every day.

Although its name indicates that it is an acute condition, ACS seems less like a sudden-onset disease when one looks at the entire disease trajectory — it’s the manifestation of lipid accumulation that starts well before the patient arrives at the emergency department or experiences symptoms of distress. As plaque builds, it becomes less stable and more apt to break, cause thrombi, and occlude coronary vessels. Patients, faced with shortness of breath, nausea, pain, and other symptoms of impending heart attack, need immediate medical support. Those who survive also need secondary prevention to reduce the likelihood of recurrent events.

One secondary intervention is the use of lipid-lowering statins for their potential to reduce CVD risk by inhibiting cholesterol synthesis and exerting pleiotropic effects. Many standard inpatient protocols employ high-dose atorvastatin therapy routinely and immediately after an ACS episode. Guidelines urge clinicians and patients to continue the medication after discharge. Studies have shown that patients benefit with reduced risk of CVD events within 4 months, but how long does the benefit continue? Researchers from the Arnold & Marie Schwartz College of Pharmacy and Health Sciences of Long Island University in Brooklyn, NY, report that patients continue to benefit for at least 5 years. Their study appears in the August 2014 issue of the Journal of Pharmacy Practice.

High-dose atorvastatin is defined as 80 mg daily. Using literature review, these authors identified 4 trials that evaluated patients’ use of 80 mg of atorvastatin daily after an ACS and compared them with patients assigned a lower-dose atorvastatin, pravastatin, or simvastatin, or placebo. These large studies looked at patients for a period between 4 months and approximately 5 years. Patients who were prescribed high-dose atorvastatin regimens experienced fewer coronary events than those on placebo or lower-dose statin regimens, and the protection lasted for at least 5 years. None of the studies were powered to address mortality.

Patients on high-dose atorvastatin discontinued drug therapy more often due to adverse reactions. The authors note that this is a clinical challenge. They recommend maintaining patients on the highest dose possible, and, if necessary, reducing the atorvastatin dose to 40 mg daily before considering switching to a different statin.