- Evidence is for patients < 70 years. Discretion for
patients> 70 years.
- 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.
- Great care in initiating thyroxine in hypothyroid patients. Use small
initial dose and careful titration to avoid exacerbation of ischaemia.
- Consider referral to dietician.
- This guideline is equally applicable for patients with non-coronary
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)
Brief synopsis of "CARE" study
"ASPIRE" study (3)
Brief synopsis of ASPIRE study:
- Scandinavian Simvastatin Survival Study Group. Randomised trial of
cholesterol lowering in 4444 patients with curonary heart disease. Lancet 1994, 344, 1383
- 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,
- 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