Statin wars following coronary revascularization--evidence-based clinical practice?

Curious Cases of the Enzymes

Life as we know it heavily relies on biological catalysis, in fact, in a very nonromantic version of it, life could be considered as a series of chemical reactions, regulated by the guarding principles of thermodynamics. In ancient times, a beating heart was a good sign of vitality, however, to me, it is actually the presence of active enzymes that counts… Though we do not usually pay attention, the history of enzymology is as old as humanity itself, and dates back to the ancient times. This paper is dedicated to these early moments of this remarkable science that touched our lives in the past and will make life a lot more efficient for humanity in the future. There was almost always a delicate, fundamentally essential relationship between mankind and the enzymes. Challenged by a very alien and hostile Nature full of predators, prehistoric men soon discovered the medicinal properties of the plants, through trial and error. In fact, they accidently discovered the enzyme inhibitors and thus, in crude terms, kindled a sparkling area of research. These plant-derivatives that acted as enzyme inhibitors helped prehistoric men in their pursuit of survival and protection from predators; in hunting and fishing… Later in history, while the underlying purposes of survival and increasing the quality of life stayed intact, the ways and means of enzymology experienced a massive transformation, as the 'trial and error' methodology of the ancients is now replaced with rational scientific theories.

Adherence to statin treatment following a myocardial infarction: an Italian population-based survey

BACKGROUND

Statins are standard therapies after myocardial infarction (MI) in the general population. In the current study, we assessed adherence to statin treatment by patients after an MI in Italy, and estimated the effect of in-hospital statin therapy on persistence in treatment during a 2-year follow-up.

PATIENTS AND METHODS

This was a retrospective cohort observation study of patients who experienced their MI between January 1, 2004 and December 31, 2005. Patients to enroll were identified by a diagnosis of MI at discharge from hospital. Previous drug therapies and hospital admissions for cardiovascular reasons in the 12 months before hospitalization for MI, statin treatment and lipid levels during hospitalization, indication for statin treatment at hospital discharge, and adherence to statin treatment in the following 24 months using an integrated analysis of administrative databases and hospital case records were evaluated. Also, factors associated either positively or negatively with consistent acute and long-term use of this efficacy-proven therapy were evaluated.

RESULTS

We identified 3,369 patients: 28.5% of patients had not been consistently treated with statins during their hospital stay for MI, and 36.2% of patients did not receive a statin prescription at hospital discharge. Of the 2,629 patients persistent with treatment during the follow-up, only 1,431 had an adherence to statins >80%. Either during the hospitalization or during the follow-up, the use of statins was negatively associated with older age and the presence of diabetes and chronic kidney disease. Lipid levels were significantly higher in treated than in untreated patients, but did not contribute to adherence to treatment. An important factor in long-term adherence to statin treatment was a statin prescription at the time of hospital discharge.

CONCLUSION

Since the statin undertreatment rate in routine care is still high, physicians need to increase the awareness of patients regarding the implications of discontinuation and/or underuse of their medications and encourage higher adherence.

Discontinuation of statin therapy following an acute myocardial infarction: a population-based study

AIMS

Randomized clinical trials have shown that statins can reduce mortality after acute myocardial infarction (AMI). However, the impact of changes in patterns of statin use, particularly stopping statins, on survival post-AMI is unknown. Our objective was to estimate the extent to which different patterns of statin use are associated with post-AMI mortality.

METHODS AND RESULTS

Population-based, cohort study, from 2002 through 2004 in the United Kingdom General Practice Research Database (GPRD), involving patients surviving 90 days after their first AMI. Past statin use was defined as any statin prescription within 90 days before AMI; statin use post-AMI as any statin prescription within 90 days after AMI. Cohort entry was at day 90 post-AMI; subjects were followed for 1 year. Four groups were identified: (i) non-users (patients never on statins); (ii) users (on statins before and continued post-AMI); (iii) starters (started statins after the event); and (iv) stoppers (stopped statins after the event). Hazard ratios (HRs) were estimated using Cox proportional hazards model. The main outcome measure was 1-year all-cause mortality. The cohort included 9939 AMI survivors (mean age: 68.4 ± 12.8 years; 60.3% men), 22.7% of whom were not prescribed a statin post-AMI. When the non-user group (n = 2124) was considered as the reference, the adjusted HRs (95% confidence intervals) of death were 0.84 (0.66-1.09) for users (n = 2026), 0.72 (0.57-0.90) for starters (n = 5652), and 1.88 (1.13-3.07) for stoppers (n = 137). Stoppers of control medications (aspirin, β-blockers, and proton pump inhibitors) were not associated with increased mortality.

CONCLUSION

Discontinuation of statins in survivors of a first AMI was relatively rare in this cohort. However, statin discontinuation was associated with higher total mortality and this may represent a biological rebound or/and a risk-treatment mismatch phenomenon, where treatment is withdrawn from very ill patients. While awaiting further research, at present statin use should only be withdrawn under judicious clinical supervision.