M1. History of Acute Coronary Syndrome in Past 6 Months?

objective

Identify patients with recent acute coronary syndrome (ACS) for whom there is a compelling need for statin therapy regardless of current lipid levels.

background

Patients with ACS are at high-risk for suffering recurrent coronary events in the near term.  Based on recent studies it is recognized that moderate- to high-dose statins are a key element of the post-ACS management strategy regardless of the lipid profile at the time of the event (see Annotation N for target levels of therapy).

recommendations

1. A lipid panel should be drawn at the time of admission for all patients with suspected acute coronary syndrome (ACS).  [C]
2. Initiating a moderate- to high-dose statin therapy prior to hospital discharge may be considered in patients admitted with ACS irrespective of their lipid profile.  [B]
3. Patients with recent ACS (within the past 6 months) should be on a moderate dose of statin therapy to reduce LDL-C level below 100 mg/dL.  [A]
4. A lower target (70 mg/dL) may be considered for very high-risk patients.  [B]

discussion

Patients with ACS are at very high-risk for early recurrence of coronary events.  Several large registries (Swedish and German post-MI registries, Mayo Clinic Registry), have demonstrated an increased risk for recurrent AMI in patients who were discharged without a statin.  The only randomized study, The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Trial (2001), confirmed that intensive LDL-lowering did reduce recurrent events for up to 18 months.  The PROVE-IT (2004) trial also supports the evidence for early initiation of statin therapy in the post-ACS population.  Therefore, moderate- to high-dose statins should be a key element of the post-ACS management strategy regardless of the lipid profile at the time of the event.

The update to NCEP-ATP III (Grundy, 2004) suggested, based on both HPS and PROVE IT, that additional benefit may be obtained by reducing LDL levels to substantially below 100 mg/dL.  This likelihood is enhanced by the finding that intensive lowering of LDL-C to well below 100 mg/dL will reduce progression of coronary atherosclerotic lesions.