Ragavendra R. Baliga, M.D
Assistant Professor
Division of Cardiology
University Of Michigan

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Question 33 of 39:

The American Heart Association Step II diet, which is low in saturated fat and cholesterol (<7% of total calories as saturated fat and <200 mg/d cholesterol), should be instituted in all patients after recovery from acute myocardial infarction.

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The American Heart Association Step II diet, which is low in saturated fat and cholesterol (<7% of total calories as saturated fat and <200 mg/d cholesterol), should be instituted in all patients after recovery from acute myocardial infarction. Patients with LDL cholesterol levels >125 mg/dL despite the AHA step II diet should be replaced on drug therapy with the goal of reducing LDL to less than 100 mg/dL. Patients with normal plasma cholesterol levels who have a high-density lipoprotein (HDL) cholesterol level less than 35 mg/dL should receive nonpharmacological therapy (eg, exercise) designed to raise it.

Approximately 70% of coronary heart disease deaths and 50% of MIs occur in patients who have previously established coronary artery disease. It is estimated that the likelihood of fatal and nonfatal MIs is four to seven times higher in patients with apparent coronary disease.

4S Trial: The Scandinavian Simvastatin Survival Study reported results in 4444 men and women with coronary heart disease and moderate hypercholesterolemia observed over 5.4 years. Coronary heart disease mortality was reduced by 42% and total mortality by 30% among those receiving simvastatin compared with placebo. It is noteworthy that the relative risk reduction seen in this trial was similar among those with the lowest quartile compared with the highest quartile of serum LDL cholesterol.

CARE Trial: The Cholesterol and Recurrent events (CARE) trial was a similar study in a population of patients who had recovered from an earlier MI and whose total cholesterol (mean 209 mg/dL) and LDL cholesterol (mean 139 mg/dL) were essentially the same as the average for the general population. In this trial 4159 patients were randomly assigned to either 40 mg of pravastatin a day or placebo. After a median follow-up of 5 years, there was a significant 24% reduction in the primary end point of fatal coronary heart disease and nonfatal confirmed MIs in the pravastatin cohort. These results firmly establish the desirability of lowering atherogenic serum lipids among patients who have recovered from an acute MI.

Lipid Treatment in the Elderly: Diet and drug treatments available for the correction of lipid abnormalities are as effective in the elderly as in the young. Clinical trials have shown that such treatment can reduce total mortality up to age 70 and the rate of recurrent coronary events up to the age 75. In addition, to date, there have been no trials to test the value of lipid control for the prevention of initial coronary events in older persons. Such treatment appears reasonable, however, in those elderly who also have other risk factors such as high blood pressure and diabetes, because their risk of a coronary attack is similar to that of persons who have already survived an attack.

LIPID Study (Long-Term Intervention With Pravastatin in Ischemic Disease): More than 9000 patients are randomly assigned to either placebo or 40 mg pravastatin daily. The trial was carried out in a group of patients with a prior history of MI or unstable angina. It was stopped prematurely because of the efficacy of pravastatin in reducing major cardiovascular events, including a 24% decrease in coronary heart disease deaths, a 23% decrease in the total mortality rate, and a 20% decrease in stroke.

LiSA Study (Lescol in Severe Atherosclerosis): Benefit has also been seen in patients with symptomatic coronary disease who were treated with fluvastatin. Patients with symptomatic coronary heart disease and hypercholesterolemia who were given fluvastatin had 71% fewer cardiac events than those in the placebo group.