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Evidence summaries

Statins for Acute Coronary Syndrome

Initiation of statin therapy in acute coronary syndrome (ACS) prior percutaneous coronary intervention appears to reduce incidence of myocardial infarction and major adverse cardiovascular events at 30 days. Level of evidence: "B"

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment).

Summary

A Cochrane review [Abstract] 1 included 18 studies with a total of 14 303 subjects. Compared to placebo or usual care, early statin therapy did not decrease the combined primary outcome of death, non-fatal myocardial infarction (MI), and stroke at one month (RR 0.93, 95% CI 0.80 to 1.08; 13 studies, n=13 484) and four months (RR 0.93, 95% CI 0.81 to 1.06; 11 studies, n=9 625) of follow-up in patients with acute coronary syndrome (ACS). There were no statistically significant risk reductions from statins for total death, total MI, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at one month and at 4 months, although there were favorable trends related to statin use for each of these endpoints. The incidence of episodes of unstable angina was significantly reduced at 4 months following ACS (RR 0.76, 95% CI 0.59 to 0.96; 9 studies, n=8 770). There were nine individuals with myopathy (elevated creatinine kinase levels > 10 times the upper limit of normal) in statin treated patients (0.13%) versus one (0.015%) in the control groups (RR 4.69, 95% CI 1.01 to 21.67; 3 studies, n=4 677). Serious muscle toxicity was mostly limited to patients treated with simvastatin 80 mg.

A meta-analysis2 included 6 studies with a total of 4 991 subjects with ACS. High-dose atorvastatin preloading before percutaneous coronary intervention (PCI) reduced incidence of MI (OR 0.73, 95% CI 0.56 to 0.94; 5 studies) and MACE (major adverse cardiovascular events; a composite of all-cause mortality, MI, and revascularization) (OR 0.80, 95% CI 0.66 to 0.97, 6 studies) at 30 days, but not all-cause mortality (OR 0.94, 95% CI 0.69 to 1.30, 4 studies). The subgroup analysis showed that ST-segment elevation MI (STEMI) patients receiving high dose of atorvastatin pre-PCI had a significant reduction in 30-day MACE, whereas in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) there was no significant improvement between groups.

A meta-analysis3 included 14 studies with a total of 3 368 subjects. Five studies included stable angina patients, 6 included NSTE-ACS patients, 2 included STEMI patients, and 1 included ACS patients. High-dose rosuvastatin preloading before PCI lead to a 58 % reduction in MACE (OR 0.42, 95 % CI 0.29 to 0.61) and a 60 % reduction in peri-procedural myocardial injury (OR 0.40, 95 % CI 0.25 to 0.63). The benefits on MACE were significant for both stable angina patients and ACS patients and for both statin naïve patients and previous statin therapy patients.

Clinical comments

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    References

    • Vale N, Nordmann AJ, Schwartz GG et al. Statins for acute coronary syndrome. Cochrane Database Syst Rev 2014;(9):CD006870. [PubMed].
    • Ma M, Bu L, Shi L, et al. Effect of loading dose of atorvastatin therapy prior to percutaneous coronary intervention in patients with acute coronary syndrome: a meta-analysis of six randomized controlled trials. Drug Des Devel Ther 2019;13():1233-1240 [PubMed]
    • Pan Y, Tan Y, Li B, et al. Efficacy of high-dose rosuvastatin preloading in patients undergoing percutaneous coronary intervention: a meta-analysis of fourteen randomized controlled trials. Lipids Health Dis 2015;14():97 [PubMed]

Primary/Secondary Keywords