Guidelines for the management of serum cholesterol in patients with established coronary artery disease

Lipid management flow chart


  1. Evidence is for patients < 70 years. Discretion for patients> 70 years.
  2. The recent SMAC advice on use of statins distinguishes between a level for patients post MI (4.8mmolll) and for other symptomatic CHD (5.5mmolll). We have chosen a level for all secondary prevention of 5.0 mmol/l aiming to include more patients in a regime for secondary prevention and for ease of use.
  3. Great care in initiating thyroxine in hypothyroid patients. Use small initial dose and careful titration to avoid exacerbation of ischaemia.
  4. Consider referral to dietician.
  5. This guideline is equally applicable for patients with non-coronary atherosclerotic disease.


Explanatory text on guidelines for the management of serum cholesterol

By mid 1994 a number of secondary prevention trials using HMG-CoA reductase inhibitors in post AMI patients had been published. In general these studies showed that for each 10% reduction in cholesterol a 20% reduction in morbidity and mortality is obtained. The same was shown by the older "non-statin 10 trials. The Scandinavian Simvastatin Survival Study (4S) trial was the first single trial to show that cholesterol reduction in post AMI patients will reduce morbidity and mortality (including total mortality).

"4S" Study (1)

Brief synopsis of "45" trial

"Care" Trial (2)

The CARE study progressed understanding by addressing the issue of secondary prevention as it applies to the majority of patients with average (not high) cholesterol values.

Brief synopsis of "CARE" study

"ASPIRE" study (3)

Brief synopsis of ASPIRE study:



  1. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with curonary heart disease. Lancet 1994, 344, 1383 - 9.
  2. Frank M et al. The Effect of Pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. New Eng J Med 1996, 335, 1001-1009.
  3. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on secondary prevention through intervention to reduce events) principal results. ASPIRE Steering Group. Heart 1996, 75 (4), 334 - 342.

Bradley Cheek 1999