Early use of statins in acute coronary syndromes

This review examines the use of HMG-CoA reductase inhibitor (statin) medications early in the clinical course of acute coronary syndrome. Available data demonstrate that there are clear clinical benefits to this practice. Numerous previous studies have documented the primary and secondary benefits of statins in the prevention of coronary events. Recent trials show that when statins are used during hospital admissions for acute coronary syndrome (ACS), patients experience decreased recurrent myocardial infarction, lower death rates, and fewer repeat hospitalizations for ischemia or revascularization. Several studies suggest that the positive effects of statins on plaque stabilization, inflammation, thrombosis, and endothelial function may be independent of lipid levels. There is also an emerging view that beneficial lipid-lowering with statins in high-risk patients has no lower limit. This information suggests that all patients admitted for ACS should be treated with statins, regardless of cholesterol levels.     

Role of statins in acute coronary syndromes

Statins reduce major coronary events and all-cause mortality in patients with coronary artery disease. Statin therapy has a proven track record for the secondary prevention of coronary artery disease. The extension of the benefit to patients with acute coronary syndromes can be expected. Apart from their lipid-lowering effects, statins significantly and favourably alter the natural history of acute coronary syndromes. Promotion of plaque stability, improvement of endothelial dysfunction and reversal of coagulation and platelet abnormalities are only some of the effects which are beneficial in the management of these patients. Early potential clinical benefits further strengthen the rationale for starting statin treatment as soon as possible after acute coronary events particularly in patients in whom invasive intervention is planned. This review examines their role in acute coronary syndromes and emphasizes the benefits of early statin therapy.     

急性冠脉综合征患者早期使用大剂量他汀类药物的临床研究

目的本研究旨在观察急性冠脉综合征患者住院期间使用大剂量他汀类药物的疗效以及观察其的安全性。方法本试验共有67位患者入选,随机分为低剂量组以及高剂量组,高剂量组有41人,低剂量组有26人。低剂量组每晚给予立普妥20 mg治疗;高剂量组每晚给予立普妥80 mg治疗,以5天为观察期,同时根据患者情况给予常规治疗以及低盐低脂饮食。比较两组治疗前、首剂24小时后以及5日后的尿酸(UA)、C-反应蛋白(CRP)、纤维蛋白原(Fbg),并且监测治疗前后的血脂、肝功能、肾功能以及其他安全性相关的症状,并统计所有入选对象的不良事件。结果 (1)两组患者入院时的尿酸、C-反应蛋白以及纤维蛋白原之间无统计学差异,两组顿服阿托伐他汀24 h后尿酸以及C-反应蛋白均有所下降(P=0.060),C-反应蛋白下降的幅度相比:32.2%vs.42.5%(P=0.012),两组服用5 d立普妥后尿酸及C-反应蛋白较前进一步下降(P<0.001),而纤维蛋白原较前增加(P=0.259),C-反应蛋白下降的幅度相比76.3%vs.84.9%(P=0.035),纤维蛋白原增高的幅度相比37.7%vs.38.4%(P=0.700)。(2)低剂量组有3.8%的病例发生MACE,高剂量组无病例发生MACE(3.8%vs.0%,P=0.016)。低剂量组有9.6%的病例发生其他不良事件,高剂量组有1.8%的病例发生其他不良事件(9.6%vs.1.8%,P=0.004)。两组治疗前后的TC、TG、HDL均无明显改变,而LDL虽有下降,但组间无差别。(3)低剂量组中有8例患者服用阿托伐他汀5 d后ALT增高,而高剂量组中有21例(31%vs.51%,P=0.059),两组均无因ALT增高>3倍而停止试验者。两组均有患者出现肾功能的下降(尿素氮46%vs.66%,P=0.057,肌酐58%vs.77%,P=0.055),但升高均在1倍以内。两组均无他汀引起的肌病。结论 (1)ACS患者早期使用大剂量阿托伐他汀能降低血清尿酸及c-反应蛋白的含量,而纤维蛋白原却有所增加。(2)ACS患者早期服用大剂量的阿托伐他汀可以减少住院期间的MACE?     

The use of statins in acute coronary syndromes: the mechanisms behind the outcomes

Lipid-lowering drugs, in particular statin treatments, have been shown to reduce the incidence of initial and recurrent coronary heart disease (CHD) events within several years of initiating therapy. This effect can be clinically detected within the first 1 to 2 years in randomized trials. Recent observational and clinical trial data suggest that lipid-lowering therapy initiated at the time of an acute coronary event can reduce recurrent events, and possibly all-cause mortality, in a much shorter period of time. The possible mechanisms by which this benefit occurs include the effect of reduced lipoprotein levels, as well as an independent effect of statins on endothelial function. Statins improve endothelial-dependent flow-mediated vasodilation by increasing the bioavailability of nitric oxide. They stabilize the plaque by modulating the inflammatory response within the vessel wall. They also decrease clot formation by decreasing the adherence of platelets to the ruptured plaque and by acting on the extrinsic coagulation cascade pathway. This review examines these effects of statins and lipoproteins on vascular function, as well as the clinical evidence supporting early treatment in acute coronary syndromes.     

Marijuana use in acute coronary syndromes

Background: Cannabis is one of the most widely used illicit substances worldwide, and it has the highest prevalence among drugs used in Egypt. Objectives: The aims were to evaluate whether the use of cannabis is a risk factor of acute coronary heart disease in low-risk, young males and to compare the cardiac pathological changes between cannabis exposed and non-exposed ischemic patients. Methods: This was a cross-sectional study that was performed on 138 male patients, aged ≤ 40 years, with acute myocardial infarction who were admitted to the Cardiac Care Unit at the University Hospital. Urine samples were submitted for toxicological analysis using a homogenous enzyme immunoassay technique to determine the substance of use. The patients were divided into three groups: group 1 (n = 23), cannabis-positive only patients; group 2 (n = 28), patients positive for any other substance of use; and group 3 (n = 34), patients negative for any substance of use. Results: Smoking was prominent, whereas group 1 had no other risk factors. In groups 1 and 2, ST-segment elevation myocardial infarction (STEMI) was dominant, whereas no ST-segment elevation myocardial infarction (NSTEMI) was prominent in group 3. Ischemic resting wall motion abnormalities were presented in 47.8% of group 1 and in only 11.8% of group 3. None of group 1 had normal coronaries, whereas 14.3% of group 3 had normal coronaries. Significant changes in echocardiography and angiography were observed between group 1 and other groups. Conclusion: Cannabis smoking could be a potential risk factor for the development of cardiac ischemia.     

Lipid-independent pleiotropic effects of statins in the management of acute coronary coronary syndromes

Opinion statement Acute coronary syndromes involve a complex interplay between the vessel wall, inflammatory cells, and the coagulation cascade. Statins possess beneficial effects that are independent of low-density lipoprotein cholesterol lowering and that have favorable effects on inflammation, the endothelium, and the coagulation cascade. There is now accumulating evidence that these lipid-independent pleiotropic effects are clinically relevant in the management of acute coronary syndromes.     

急性冠状动脉综合征患者应尽早服用他汀类药物

~~急性冠状动脉综合征患者应尽早服用他汀类药物@赵水平$中南大学湘雅第二医院心内科!长沙4100111 Stenestrand U, Wallentin L. Early statin treatment following acute myocardial infarction and 1-year survival. JAMA, 2001, 288 : 430-436. 2 Thompso FT. Clinical relevance of statins: instituting treatment early in caute coronary syndrome patients. Atherosclerosis, 2001, 2 Suppl: 15-19. 3 Aronow HD, Topol EJ, Roe MT, et al. Effects of lipid-lowering therpay on early …     

Early statin therapy in acute coronary syndromes

Patients who survive an acute coronary syndrome of unstable angina or myocardial infarction are at much higher risk of a recurrent event within the following year than patients with stable coronary syndromes. Statin therapy is justified for many of these patients, not only for long-term benefit but also to reduce the risk of recurrent events within weeks of the primary event. The mechanisms that underlie this benefit are probably related to improvements in endothelial function, a decrease in vascular inflammation, and reduced prothrombotic factors. The effects of statins may be mediated by cholesterol reduction, cholesterol-independent effects (particularly decreasing isoprenoids), and mechanisms that are independent of inhibiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase. Observational studies consistently show an early reduction in mortality with statin therapy started before discharge from hospital after an acute coronary syndrome. Several randomized controlled trials also support an early benefit of risk reduction from statins started during the hospital admission for an acute coronary syndrome. Early statin therapy is also related to improved compliance and use of statins several years after a coronary event. Thus, early statin therapy may improve both early and long-term secondary prevention efforts.     

Early statin therapy in acute coronary syndromes

Patients who survive an acute coronary syndrome are at much higher risk of a recurrent event within the following year than patients with stable coronary syndromes. Risk factor modification, including statin therapy, lowers the risk of recurrent events over many years, but also to reduces the high risk of an another event within the weeks to months following the initial acute coronary syndrome. The mechanisms that contribute to this benefit are likely related to improvements in endothelial function, a decrease in vascular inflammation, and reduced prothrombotic factors. The effects of statins may be mediated by cholesterol reduction, cholesterol-independent effects (particularly by decreasing isoprenoids), and mechanisms that are independent of inhibiting HMG CoA reductase. Observational studies show an early reduction in mortality with statin therapy started before discharge from hospital after an acute coronary syndrome. Several randomized controlled trials also support a rapid reduction in the risk of recurrent events after starting statins during the hospital admission for an acute coronary syndrome. Early statin therapy is also related to improved compliance and use of statins several years after a coronary event. Thus early statin therapy may improve both early and long-term secondary prevention efforts.     

Mechanisms of acute coronary syndromes and the potential role of statins

The conventional concepts of the pathogenesis of acute coronary syndromes are changing. High-risk lesions are not necessarily the angiographicaly 'tight' stenoses. Rather, vulnerable lesions are those that are unstable, with a large lipid core and a thin fibrous cap. Plaque instability is closely related to the development of inflammation within the intima and acute coronary syndromes result from rupture of a vulnerable atherosclerotic plaque. Stabilization of lesions by modification of structure and content, rather than simple improvement in the luminal diameter, provides a new therapeutic target. Stabilization may be accomplished through lifestyle changes and appropriate pharmacologic therapy. In the past few years, it has become evident that a major beneficial effect of statins is to induce plaque stability and regression. In fact, statins, in addition to lowering low-density lipoprotein cholesterol, have a variety of pleiotropic, or cholesterol-independent, effects that make them a particularly suitable choice in patients with acute coronary syndromes. Among these are improvements in endothelial function, smooth muscle cells, thrombus formation/platelet function, and inflammation.     

他汀类药物在急性冠状动脉综合征中抗炎作用的研究进展

［摘要］　急性冠状动脉综合征（ACS）是常见的冠状动脉粥样硬化性心脏病的急症,炎症在动脉粥样硬化过程中起重要作用。3-羟基-3-甲基戊二酰辅酶A还原酶抑制剂他汀类药物现已广泛应用于冠心病的一级、二级预防,越来越多的证据显示他汀类药物具有显著抗炎作用。该文对他汀类药物在ACS中的抗炎作用作一简要的综述。     

Early invasive strategies for acute coronary syndromes

Early coronary angiography and percutaneous or operative revascularization is now the treatment of choice for both ST- and non-ST-segment elevation acute coronary syndromes (ACS). In non-ST-segment elevation ACS this strategy produces a 18% to 22% reduction in ischemic outcomes at 6 months and prevents 1.7 deaths, 2.0 nonfatal infarcts and 20 readmissions per 100 treated patients at 1-year follow-up. Early angiography allows definition of coronary anatomy and assessment of left ventricular function, both important predictors of long-term risk. Intracoronary stenting and intravenous glycoprotein IIb/IIIa antagonists have improved outcome in percutaneous revascularization and should be used in the majority of ACS patients undergoing PCI. Initial costs are higher with an early invasive strategy; however, these are offset by reductions in rehospitalizations and later ischemic complications.