A 68-year-old woman arrives in the emergency department with chest pain. The findings on an electrocardiogram are consistent with ischemia. She still has pain despite intravenous administration of nitroglycerine. She is taken to the cardiac catheterization laboratory, and she is found to have a 90% stenosis of the left circumflex artery. She undergoes a successful angioplasty. The remainder of her coronary arteries have minimal disease. She is discharged within 48 hours, at which time her lipid profile ordered in the emergency department is still not available.
The decision to be made postdischarge for this patient is when to initiate statin therapy.
This case illustrates the appropriate timing of initiation of lipid-lowering therapy. Currently, several trials, including PROVE-IT and MIRACL, suggest that early and aggressive initiation of statin therapy can reduce recurrent ischemia as early as 30 days. Additionally, improvement of endothelial function is evident within the first month of statin use. Finally, long-term compliance is much better when secondary prevention strategies such as statin, aspirin, and β-blocker therapy are initiated during the hospital stay. Initiation during the hospital stay reduces the likelihood that physicians caring for patients with coronary disease will overlook these medications and ensures that patients understand that these medications are inexorably linked to reducing the risk of another ischemic event.
A study examining compliance with secondary prevention strategies initiated at hospital discharge found not only tremendous increase in the number of patients on lipid-lowering therapy with these medications at 1 year postdischarge, but also saw a 50% reduction in recurrent ischemic events among patients who started therapy at the time of their hospitalization.
21 Two years after the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) was implemented, aspirin use increased from 68% to 92%; β-blocker use, from 12% to 62%; angiotensin-converting enzyme use, from 6% to 58%; and statin use, from 6% to 86%. Additionally, the number of patients with an LDL-C level of less than 100 mg/dL increased from 6% to 86%. These findings have led to the recommendation from the American College of Cardiology and the American Heart Association that all patients be discharged from a hospitalization for an acute ischemic event on statin therapy unless contraindicated.
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