November 2006

An 80-year-old woman with hypertension, diabetes, and osteoarthritis experienced an episode of atrial fibrillation 1 year earlier, causing presyncope accompanied by palpitations, but no other symptoms.

To evaluate whether the early use of statins would reduce cardiovascular events, we conducted a prospective, randomized trial that included 486 patients with acute myocardial infarction and normal total cholesterol levels, of whom 241 patients received statin therapy. The statin group had a lower risk of congestive heart failure and symptomatic myocardial ischemia, which indicates that early treatment with statins reduces recurrent cardiovascular events.

Numerous clinical trials have shown that HMG CoA reductase inhibitor (statin) therapy reduces the risk of myocardial infarction (MI), stroke, and mortality in patients with cardiovascular disease.

The role of combination therapy with an oral anticoagulant and aspirin for patients recovering from an acute coronary syndrome is still being debated. The results of our meta-analysis showed that treatment with aspirin plus warfarin at international normalized ratio values between 2 and 3 significantly reduces the risk of major adverse events compared with aspirin alone but also increases the risk of major bleeding. For every 100 patients receiving combination therapy, approximately 3 major adverse events are prevented and 1 major hemorrhage occurs.

The study by Andreotti and Testa from Rome, Italy, was a retrospective lit erature review and meta-analysis of treatment with aspirin and warfarin (Coumadin) in survivors of acute coronary syndromes.

We performed a meta-analysis of the effect of long-term treatment with antiarrhythmic drugs for the prevention of recurrent atrial fibrillation after conversion to sinus rhythm. We found that several class IA, IC, and III drugs are effective in maintaining sinus rhythm, but virtually all of them increase adverse effects, including proarrhythmia. In addition, class IA drugs are associated with increased mortality. The final risk-benefit ratio of antiarrhythmic drugs on clinically relevant outcomes is still unclear.

Lafuente-Lafuente and colleagues performed a meta-analysis of 44 studies of 11 322 patients in randomized controlled trials of persons with atrial fibrillation who received antiarrhythmic drugs after restoration of sinus rhythm.

Patients who survive an acute coronary syndrome are at much higher risk of a recurrent event within the following month than patients with stable coronary syndromes. Statin therapy lowers the risk of recurrent events for many years but also reduces the risk of another event within the weeks to months following the initial acute coronary syndrome. The mechanisms that contribute to this benefit are likely related to improved endothelial function, decreased vascular inflammation, and reduced prothrombotic factors. Observation studies show an early reduction in mortality with statin therapy started before discharge from the hospital after an acute coronary syndrome.