title: Statins for acute coronary syndrome.
abstract: BACKGROUND
  The early period following the onset of acute coronary syndrome (ACS) represents a critical stage of coronary heart disease, with a high risk of recurrent events and deaths. The short-term effects of early treatment with statins on patient-relevant outcomes in patients suffering from ACS are unclear. This is an update of a review previously published in 2011.
  
  
  OBJECTIVE
  To assess the effects, both harms and benefits, of early administered statins in patients with ACS, in terms of mortality and cardiovascular events.
  
  
  METHODS
  We updated the searches of CENTRAL (2013, Issue 3), MEDLINE (Ovid) (1946 to April Week 1 2013), EMBASE (Ovid) (1947 to 2013 Week 14), and CINAHL (EBSCO) (1938 to 2013) on 12 April 2013. We applied no language restrictions. We supplemented the search by contacting experts in the field, by reviewing the reference lists of reviews and editorials on the topic, and by searching trial registries.
  
  
  METHODS
  Randomized controlled trials (RCTs) comparing statins with placebo or usual care, with initiation of statin therapy within 14 days following the onset of ACS, follow-up of at least 30 days, and reporting at least one clinical outcome.
  
  
  METHODS
  Two authors independently assessed risk of bias and extracted data. We calculated risk ratios (RRs) for all outcomes in the treatment and control groups and pooled data using random-effects models.
  
  
  RESULTS
  Eighteen studies (14,303 patients) compared early statin treatment versus placebo or no treatment in patients with ACS. The new search did not identify any new studies for inclusion. There were some concerns about risk of bias and imprecision of summary estimates. Based on moderate quality evidence, early statin therapy did not decrease the combined primary outcome of death, non-fatal myocardial infarction, and stroke at one month (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) or four months (RR 0.93, 95% CI 0.81 to 1.06) of follow-up when compared to placebo or no treatment. There were no statistically significant risk reductions from statins for total death, total myocardial infarction, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at one month or at four months, although there were favorable trends related to statin use for each of these endpoints. Moderate quality evidence suggests that the incidence of unstable angina was significantly reduced at four months following ACS (RR 0.76, 95% CI 0.59 to 0.96). There were nine individuals with myopathy (elevated creatinine kinase levels more than 10 times the upper limit of normal) in statin-treated patients (0.13%) versus one (0.015%) in the control groups. Serious muscle toxicity was mostly limited to patients treated with simvastatin 80 mg.
  
  
  CONCLUSIONS
  Based on moderate quality evidence, due to concerns about risk of bias and imprecision, initiation of statin therapy within 14 days following ACS does not reduce death, myocardial infarction, or stroke up to four months, but reduces the occurrence of unstable angina at four months following ACS. Serious side effects were rare.
authors.affiliation: Family Medicine, St Mary's Hospital, McGill University, 377 Rue Jean Brilliant, Montreal, QC, Canada, H3T 1M5.
authors.forename: Noah
authors.initials: N
authors.lastname: Vale
authors.forename: Alain J
authors.initials: AJ
authors.lastname: Nordmann
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Schwartz
authors.forename: James
authors.initials: J
authors.lastname: de Lemos
authors.forename: Furio
authors.initials: F
authors.lastname: Colivicchi
authors.forename: Frank
authors.initials: F
authors.lastname: den Hartog
authors.forename: Petr
authors.initials: P
authors.lastname: Ostadal
authors.forename: Stella M
authors.initials: SM
authors.lastname: Macin
authors.forename: Anho H
authors.initials: AH
authors.lastname: Liem
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.forename: Neera
authors.initials: N
authors.lastname: Bhatnagar
authors.forename: Heiner C
authors.initials: HC
authors.lastname: Bucher
authors.forename: Matthias
authors.initials: M
authors.lastname: Briel
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000401:mortality; D000789:Angina, Unstable / Q000517:prevention & control; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death; D004334:Drug Administration Schedule; D006333:Heart Failure / Q000517:prevention & control; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D009203:Myocardial Infarction / Q000517:prevention & control; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000517:prevention & control
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors