Volume 211 - Issue 6
Intensive lipid‐lowering therapy in the 12 months after an acute coronary syndrome in Australia: an observational analysis
Authors: David B Brieger, James Weaver and Leonard Kritharides
Med J Aust 2019; 211 (6): 285-285.e1. || doi: 10.5694/mja2.50323
Published online: 16 September 2019
Published online: 16 September 2019
Correction(s) for this article:
Erratum | Published online: 6 May 2019
In reply
In reply: We thank Dimmitt and Martin for their observations about our article.1 We do not believe the benefit of high dose therapy to be in dispute. It is misleading to suggest that the failure to show a reduction of events with high intensity therapy within 3–6 months after institution of treatment in the cited Cochrane review2 equates to no effect overall. The true benefits of statins become most apparent more than 12 months after starting therapy, and this is true for the comparison between high and low doses. While we acknowledge that the trials comparing statin dose do not show a significant reduction in coronary heart disease mortality, a meta‐analysis of the trials of high intensity therapy does result in a 15% reduction in myocardial infarction, a 19% reduction in coronary revascularisation, and a 14% reduction in stroke at 12‐month follow‐up compared with conventional dosage.3 The 2018 United States guidelines for the management of blood cholesterol,4 which supersede those cited by Dimmitt and Martin,5 describe this benefit, and recommend initiation of high intensity statin therapy in patients following an acute coronary syndrome. Our study suggests an important advantage of early initiation is to maximise the likelihood that these patients remain on this therapy in the long term.
While we agree the adverse effects of statins are recognised as contributing to suboptimal compliance, the reported 29‐fold increase in myopathy and a ninefold increase in liver dysfunction with high dose statin use would appear to be far greater than incidences reported in the wider literature.6 Strategies to minimise these, such as temporary cessation and rechallenge, prescription of alternative statins, and combination with alternative lipid‐lowering agents have been well described.6
Secondary prevention following an acute coronary syndrome is a challenging endeavour, with recurrent event rates unacceptably high in Australia.7 We believe that the additional reduction in coronary events associated with increasing statin dose is comparable to combining other secondary prevention measures, as reported by Dimmitt and Martin, which justifies current guideline recommendations.8
Competing interests
No relevant disclosures.
References
- Brieger D, D'Souza M, Huyn K, et al. Intensive lipid‐lowering therapy in the 12 months after an acute coronary syndrome in Australia: an observational analysis. Med J Aust 2019; 210: 80–85. https://www.mja.com.au/journal/2019/210/2/intensive-lipid-lowering-therapy-12-months-after-acute-coronary-syndrome
- Nordmann A, Schwartz G, Vale N, et al. Cochrane corner: early statin therapy in acute coronary syndromes — what clinical benefit? Heart 2016; 102: 653–654.
- Cholesterol Treatment Trialists Collaboration; Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta‐analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010; 376: 1670–1681.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 73: 3168–3209.
- Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129 (Suppl): S1–S45.
- Stroes ES, Thompson PD, Corsini A, et al. Statin‐associated muscle symptoms: impact on statin therapy‐European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Eur Heart J 2015; 36: 1012–1022.
- Brieger DB, Chew DP, Redfern J, Ellis C, Briffa TG, Howell TE, et al. Survival after an acute coronary syndrome: 18‐month outcomes from the Australian and New Zealand SNAPSHOT ACS study. Med J Aust 2015; 203: 368. https://www.mja.com.au/journal/2015/203/9/survival-after-acute-coronary-syndrome-18-month-outcomes-australian-and-new
- Brieger D. Optimising acute care and secondary prevention for patients with acute coronary syndrome. Med J Aust 2014; 201: S88–S90. https://www.mja.com.au/journal/2014/201/10/optimising-acute-care-and-secondary-prevention-patients-acute-coronary-syndrome