For decades, we’ve been giving an aspirin to every patient suspected of having acute coronary syndrome (ACS) who enters the emergency department. The ISIS-2 trial published in The Lancet in August 1988 (“Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial Infarction”) concluded that, of patients ultimately having an ST elevation myocardial infarction 9STEMI), the number needed to treat (NNT) to prevent one death at 30 days was 42. The death rate went from 11.8 percent to 9.4 percent.
Explore This IssueACEP Now: Vol 35 – No 09 – September 2016
However, there are a couple things to consider about ISIS-2: First, chest pain patients with a STEMI represent a very small fraction of the suspected ACS patients presenting to the emergency department. Second, the death rate from STEMI is now about 5 percent, much lower than in 1988. Despite these two factors that would substantially mitigate the efficacy of aspirin in chest pain patients, we still give it to everyone who has chest pain suspected to be ACS.
Nobody argues with giving aspirin even when the vast majority who get it will likely receive no benefit. One aspirin may help a very small percentage of suspected ACS patients and isn’t going to hurt anyone—a no-brainer.
In many ways, however, the case for giving high-dose statins to potential ACS patients may be potentially stronger than that for aspirin.
Statins have long been known to have other effects besides lowering LDL cholesterol. These pleiotropic effects include decreasing platelet adhesion, inhibiting thrombosis, improving endothelial function, decreasing inflammation, and stabilizing plaque. The fundamental question is whether these pleiotropic effects (and others that may be unknown) can acutely benefit ACS patients.
Unfortunately, as of yet, there is no study that hits the nail directly on the head regarding the benefits of statins given in the emergency department, but there are many that suggest that there may be a benefit.
THE CASE FOR EARLY STATINS
Below are some studies that indirectly support the idea that statins should be given to every suspected ACS patient in the emergency department. Unfortunately, as of yet, there is no study that hits the nail directly on the head regarding the benefits of statins given in the emergency department, but there are many that suggest that there may be a benefit.
Saab FA, Eagle KA, Kline-Rogers E, et al. COMPARISON OF OUTCOMES IN ACUTE CORONARY SYNDROME IN PATIENTS RECEIVING STATINS WITHIN 24 HOURS OF ONSET VERSUS AT LATER TIMES. Am J Cardiol. 2004;94(9):1166-1168.
This large study by Saab et al looked at 1,639 statin-naive ACS patients who received statins within 24 hours of admission and found that inpatient mortality wasn’t significantly lower (1.64 percent versus 2.26 percent) compared with those who received them later than 24 hours after admission. There were, however, substantial differences in other outcomes:
- Inpatient pulmonary edema (6.9 percent versus 15.8 percent; NNT = 11)
- Cardiogenic shock (2.2 percent versus 7.3 percent; NNT = 20)
- Atrial flutter or fibrillation (5.2 percent versus 9.0 percent; NNT = 21)
- Major bleeding (4.9 percent versus 10.4 percent; NNT = 18)
- The composite outcome of death-reinfarction-stroke (7.0 percent versus 10.4 percent; NNT = 29)
- The six-month composite outcome of death-myocardial infarction (MI)-stroke-rehospitalization (32.8 percent versus 38.3 percent; NNT = 18)
Ferrières J, Cambou JP, Guéret P, et al. EFFECT OF EARLY INITIATION OF STATINS ON SURVIVAL IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION (THE USIC 2000 REGISTRY). Am J Cardiol. 2005;95(4):486-489.
In a nonrandomized registry study of 2,210 acute myocardial infarction (AMI) statin-naive patients receiving statins within 48 hours of admission, there was a hazard ratio of 0.57 for a one-year prognosis for cardiovascular deaths and/or recurrent MIs.
Lenderink T, Boersma, E, Gitt AK, et al. PATIENTS USING STATIN TREATMENT WITHIN 24 HOURS AFTER ADMISSION FOR ST-ELEVATION ACUTE CORONARY SYNDROMES HAD LOWER MORTALITY THAN NON-USERS: A REPORT FROM THE FIRST EURO HEART SURVEY ON ACUTE CORONARY SYNDROMES. Eur Hear J. 2006;27(15):1799-1804.
There isn’t much I can add here—just reading the title gives you the results.
Fonarow GC, Wright RS, Spencer FA, et al. EFFECT OF STATIN USE WITHIN THE FIRST 24 HOURS OF ADMISSION FOR ACUTE MYOCARDIAL INFARCTION ON EARLY MORBIDITY AND MORTALITY. Am J Cardiol. 2005;96(5):611-616.
This registry analysis (174,635 AMI patients from 1,230 hospitals) found numbers that were too good to be true. Patients started on early statins had an in-hospital mortality of 4 percent; the rate was 5.3 percent in patients already taking them and 15.4 percent in those not treated with statins. Although I’m trying to make the case for early statins, even I can’t believe the results of this study.