2 decades of MI

A Cardiology Today Editorial Board member discusses progress in the management and treatment of MI.

Issue: March 2017

Editor’s Note: Cardiology Today is celebrating its 20th anniversary in 2017. We are reaching out to experts in cardiology for their take on changes in CV medicine since the publication launched in 1997. In this issue, Joseph S. Alpert, MD, focuses on MI.

Statin therapy first became available in 1987 when lovastatin (Mevacor, Merck) was approved for patient use. Over the next 10 years, numerous clinical trials demonstrated that statins reduced morbidity and mortality from various forms of atherosclerotic disease by a substantial, statistically significant amount. In post-MI patients, the reduction was as high as 40% when the drug was used chronically. Lower but still statistically significant benefits were demonstrated in lower-risk patients, for example, individuals at high risk for developing atherosclerosis but who had not yet shown any clinical signs or symptoms of ischemic CVD. Statin therapy in a variety of clinical trials was shown to reduce the risk for first or subsequent MI, stroke and HF from ischemic heart disease. Statins now have a class 1, level of evidence A guideline indication for all atherosclerotic disease states.

Compared with 20 years ago, cardiologists are now much more aggressive about using high-dose statin therapy acutely in patients with MI and unstable angina. All standard critical care unit protocols in U.S. hospitals prescribe high-dose statin therapy for patients admitted with ACS.

Therapy for ischemic heart disease has had a remarkable effect on patients with MI. Mortality and morbidity have fallen dramatically over the last 40 years. Developments that have played a role in this remarkable improvement include: critical-care-unit care of patients; statins; ACE inhibitors and angiotensin receptor blockers; anticoagulants and antiplatelet agents; and, of course, PCI and CABG. All of these, alongside widespread understanding by the patients of the factors that lead to atherosclerosis with consequent lifestyle changes, has led to this excellent result.

When I was a medical student more than 40 years ago, one-third of patients who entered the hospital with an acute MI died within 30 days. That figure is now 5% to 6%, even though the patients are much older now and at higher risk for mortality. This has truly been a remarkable improvement. Statins are one of the most important factors in the improved outlook for patients with atherosclerotic disease.

The biggest problem is that many patients stop their statins for reasons that are not rational. Side effects from statins are minimal and usually tolerated. It is very rare that an individual develops true myositis and the drug must be stopped. The common cramps and muscle aches are not dangerous and usually can be overcome with reduced dosage or even every-other-day dosage. There is a slight tendency toward glucose intolerance, but this is minimal compared with the major decrease in CV events. Once patients fully understand the benefits, they will usually adhere to statin therapy. It needs to be taken lifelong, but the benefit in very elderly patients is debatable.

The European Society of Cardiology and the American College of Cardiology/American Heart Association disagree on whether patients need to have their lipid values followed regularly and the statin dose titrated to achieve a recommended LDL level. The current ACC/AHA recommendations are to treat with low-dose or high-dose statin depending on the level of risk. As results from the outcome trials of the PCSK9 inhibitors emerge, we will have more information as to which strategy is the correct one. I personally do a mixed strategy, with occasional checks of lipid levels to make sure patients are adherent and are getting an effective dose of statin.

– Joseph S. Alpert, MD
Cardiology Today Editorial Board Member
University of Arizona Health Science Center
Disclosure: Alpert reports no relevant financial disclosures.