Recent Trials Exploring Statin Efficacy in ACS The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Trial First large-scale (>2,000 patients) clinical trial on effect of aggressive cholesterol lowering in ACS patients. [Note: Results will be summarized in the next issue of LipidManagement™.] Within 1 to 4 days after hospital admission, patients were randomly assigned to atorvastatin 80 mg/day or placebo, with follow-up after 16 weeks of treatment. Primary end point: time from randomization to first occurrence of death, recurrent nonfatal MI, resuscitated cardiac arrest, or worsening angina with new objective evidence of ischemia requiring emergency rehospitalization. Secondary end points: primary plus stroke, coronary revascularization, worsening congestive heart failure, and worsening angina without new objective evidence of ischemia.1 The Randomized Lipid-Coronary Artery Disease (L-CAD) Study Seventy patients who were prescribed pravastatin an average of 6 days after a coronary event were compared with 56 patients who received standard care with antilipidemic therapy at the discretion of their family physician. Patients were followed for 24 months. In the pravastatin group, TC was significantly reduced by an average of 20% and LDL-C by 28% (P<0.001) over the study period. In the "standard-care" group, both values remained close to baseline during the entire study. End points: total mortality, cardiovascular death, nonfatal MI, need for coronary intervention, stroke, and new onset of peripheral vascular disease, as well as angiographic changes at 6 and 24 months. After 24 months, 16 of the 70 patients (23%) in the pravastatin group had experienced a clinical end point compared with 29 of the 56 patients (52%) in the standard-care group. Conclusion: This study illustrates that pravastatin—in combination with cholestyramine and/or nicotinic acid when necessary—used immediately after ACS, can prevent progression and produce regression of coronary lesions.2 The Swedish Registry Study Prospective cohort study compared 5,528 MI patients who received statins at or before hospital discharge with 14,071 who did not. Main outcome measure: relative risk of 1-year mortality according to treatment. At 1 year, unadjusted mortality was 9.3% (1,307 deaths) in the no-statin group and 4.0% (219 deaths) in the statin-treatment group. Conclusion: Early initiation of statin treatment in MI patients is associated with reduced 1-year mortality.3 References 1. Schwartz GG, Oliver MF, Ezekowitz MD, et al. Rationale and design of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study that evaluates atorvastatin in unstable angina pectoris and in non–Q-wave acute myocardial infarction. Am J Cardiol. 1998;81:578-581. 2. Arntz H-R, Agrawal R, Wunderlich W, et al. Beneficial effects of pravastatin (± colestyramine/niacin) initiated immediately after a coronary event (the Randomized Lipid-Coronary Artery Disease [L-CAD] Study). Am J Cardiol. 2000;86(suppl):1293-1298. 3. Stenestrand U, Wallentin L, for the Swedish Register of Cardiac Intensive Care (RIKS-HIA). Early statin treatment following acute myocardial infarction and 1-year survival. JAMA. 2001;285:430-436.