Yet another use for statins?

The use of statins to treat hyperlipidemia is well established. In addition, several randomized studies, such as that from the Scandinavian Simvastatin Survival Study Group,¹ have demonstrated that long-term statin therapy in patients with stable coronary artery disease (CAD) improves prognosis in terms of subsequent cardiovascular events. Not only is prognosis in these patients better (secondary prevention), but so is primary prevention in those individuals with hyperlipidemia but no overt CAD.² One area that merits further investigation with statins is the form of CAD with the highest morbidity and mortality—namely, the acute coronary syndromes (ACS). Nonrandomized studies to date have demonstrated that statins can be helpful in patients with acute coronary syndromes, for example those patients who were already receiving statins when they underwent a percutaneous coronary intervention (PCI) had a better perioprocedural prognosis. What was required next was a randomized trial to test this hypothesis. This was the purpose of the ARMYDA (Atorvastatin for Reduction of Myocardial Damage during Angioplasty) ACS trial, a successor to the original ARMYDA trial that was centered on patients undergoing elective PCI for stable angina.³ In the current ARMYDA-ACS trial, 171 patients in Italian hospitals with non—ST-segment ACS were randomized to pretreatment with atorvastatin or placebo. The dose of atorvastatin was 80 mg given 12 hr before the PCI with a further 40 mg preprocedural dose. After the procedure the daily dose of atorvastatin was 40 mg. The primary endpoint was a major adverse cardiac event, ie, death, myocardial infraction, or unplanned target vessel coronary revascularization (either PCI or coronary artery bypass graft). Their results showed a statistically significant difference between the statin and placebo treatment arms (5% vs 17%; P = .01). There was also a significantly lower periprocedural elevation of cardiac enzymes, which was consistent with the reduction in the incidence of postprocedure acute myocardial infarctions.

What explains this dramatic new benefit of statins? It can't be just due to the lowering of serum cholesterol levels (especially low-density lipoprotein cholesterol) because of the short time frame, so once again cardiologists are postulating that the anti-inflammatory effects of statins play a large role in one of their beneficial actions.⁴ In that regard, Drs Patti and Di Sciascio note that in the present study statins seem to work best (in terms of reducing subsequent cardiac events) in those patients with the higher baseline levels of inflammatory makers such as C-reactive protein.

Whether that is due to anti-inflammatory effects or other, as-yet undiscovered attributes, the bottom line is that another use for statins may soon be listed in the various CAD guidelines!