Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Long-Term Benefit of Statin Therapy Initiated during Hospitalization for an Acute Coronary Syndrome

A Systematic Review of Randomized Trials



This study sought to determine if the initiation of statin (HMG-CoA reductase inhibitor) therapy during acute coronary syndromes reduces long-term mortality and other adverse cardiac outcomes.


Initiation of statin therapy during acute coronary syndromes has not been shown to reduce mortality, myocardial infarction or stroke within 4 months of follow-up.


Clinical trials that randomized patients with acute coronary syndromes to early statin therapy compared with less intensive lipid reduction (placebo/lower-dose statin/usual care), and reported long-term outcomes were included for analysis.


In all, there were seven studies (L-CAD, PTT, FLORIDA, Colivicchi et al., PROVE-IT, ESTABLISH, and A-to-Z) with 9553 patients who started statin therapy within 12 days of hospital presentation. The incidence of all-cause mortality was 3.4% in the statin group versus 4.6% in the less intensive lipid reduction group over a weighted mean follow-up of 22.9 months (relative risk [RR] 0.74; 95% CI 0.61, 0.90; p = 0.003). The number of patients needed to treat to prevent one death was 84 patients. Similarly, the incidence of cardiovascular mortality in the statin versus the less intensive lipid reduction group was 2.4% versus 3.3% (RR 0.74; 95% CI 0.58, 0.93; p = 0.010), unstable angina 4.1% versus 5.0% (RR 0.81; 95% CI 0.68, 0.98; p = 0.027), revascularization 11.2% versus 12.9% (RR 0.86; 95% CI 0.78, 0.96; p = 0.006), stroke 1.1% versus 1.2% (RR 0.90; 95% CI 0.62, 1.30; p = 0.56), and myocardial infarction 6.6% versus 7.0% (RR 0.94; 95% CI 0.81, 1.09; p = 0.41).


The benefit of early initiation of statin therapy during acute coronary syndromes slowly accrues over time so that a survival advantage is seen around 24 months. Relatively few patients need to be treated to prevent one death over this time period. Furthermore, this approach significantly reduces unstable angina and the need for revascularization.

This is a preview of subscription content, log in to check access.

Fig. 1
Table I
Table II
Table III
Table IV
Fig. 2
Table V
Fig. 3
Fig. 4


  1. 1.

    Aronow HD, Topol EJ, Roe MT, et al. Effect of lipid-lowering therapy on early mortality after acute coronary syndromes: an observational study. Lancet 2001; 357: 1063–8.

  2. 2.

    Newby LK, Kristinsson A, Bhapkar MV, et al. Early statin initiation and outcomes in patients with acute coronary syndromes. JAMA 2002; 287: 3087–95.

  3. 3.

    Michels KB, Braunwald E. Estimating treatment effects from observational data: dissonant and resonant notes from the SYMPHONY trials. JAMA 2002; 287: 3130–2.

  4. 4.

    Bavry AA, Bhatt DL. Interpreting observational studies: look before you leap. J Clin Epidemiol 2006; 59: 763–4.

  5. 5.

    Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study. A randomized controlled trial. JAMA 2001; 285: 1711–8.

  6. 6.

    Briel M, Schwartz GG, Thompson PL, et al. Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes: a meta-analysis of randomized controlled trials. JAMA 2006; 295: 2046–56.

  7. 7.

    Bhatt DL, Steg PG, Ohman EM, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA 2006; 295: 180–9.

  8. 8.

    Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17: 1–12.

  9. 9.

    Arntz HR, 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: 1293–8.

  10. 10.

    Kayikcioglu M, Can L, Kultursay H, et al. Early use of pravastatin in patients with acute myocardial infarction undergoing coronary angioplasty. Acta Cardiol 2002; 57: 295–302.

  11. 11.

    Liem AH, van Boven AJ, Veeger NJ, et al. Effect of fluvastatin on ischaemia following acute myocardial infarction: a randomized trial. Eur Heart J 2002; 23: 1931–7.

  12. 12.

    Colivicchi F, Guido V, Tubaro M, et al. Effects of atorvastatin 80mg daily early after onset of unstable angina pectoris or non-Q-wave myocardial infarction. Am J Cardiol 2002; 90: 872–4.

  13. 13.

    Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004; 350: 1495–504.

  14. 14.

    Okazaki S, Yokoyama T, Miyauchi K, et al. Early statin treatment in patients with acute coronary syndromes: demonstration of the beneficial effect on atherosclerotic lesions by serial volumetric intravascular ultrasound analysis during half a year after coronary event. The ESTABLISH study. Circulation 2004; 110: 1061–8.

  15. 15.

    De Lemos JA, Blazing MA, Wiviott SD, et al. Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. JAMA 2004; 292: 1307–16.

  16. 16.

    Califf RM, DeMets DL. Principles from clinical trials relevant to clinical practice: part I. Circulation 2002; 106: 1015–21.

  17. 17.

    Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383–9.

  18. 18.

    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial Investigators. N Engl J Med 1996; 335: 1001–9.

  19. 19.

    Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA 1998; 279: 1615–22.

  20. 20.

    Fonarow GC, Gheorghiade M, Abraham WT. Importance of in-hospital initiation of evidence-based medical therapies for heart failure-a review. Am J Cardiol 2004; 94: 1155–60.

  21. 21.

    Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005; 366: 1267–78.

  22. 22.

    Bonetti PO, Lerman LO, Napoli C, et al. Statin effects beyond lipid lowering: are they clinically relevant? Eur Heart J 2003; 24: 225–48.

  23. 23.

    Shishebor MH, Patel T, Bhatt DL. Using statins to treat inflammation in acute coronary syndromes: are we there yet? Cleve Clin J Med 2006; 73: 760–6.

  24. 24.

    LUNAR IIIb: study comparing rosuvastatin and atorvastatin in subjects with acute coronary syndromes [online]. Available from URL: http://www.clinicaltrials.gov/ct/show/NCT00214360 [Accessed 2007 Mar 14].

  25. 25.

    Cannon CP, Steinberg BA, Murphy SA, et al. Meta-analysis of cardiovascular outcomes trials comparing intensive versus moderate statin therapy. J Am Coll Cardiol 2006; 48: 438–45.

Download references


No sources of funding were used in conducting this research

Dr Bavry discloses the following relationship: Honoraria — Genesis. Dr Askari discloses the following relationship: Speakers bureau — Pfizer. Dr Bhatt discloses the following relationships: Speakers bureau — Bristol Myers Squibb, Sanofi Aventis, The Medicines Company. Honoraria — Astra Zeneca, Bristol Myers Squibb, Eisai, Eli Lilly, Glaxo Smith Kline, Millennium, Paringenix, PDL, Sanofi Aventis, Schering Plough, The Medicines Company. Consultant/Advisory Board — Astra Zeneca, Bristol Myers Squibb, Eisai, Eli Lilly, Glaxo Smith Kline, Millennium, Paringenix, PDL, Sanofi Aventis, Schering Plough, The Medicines Company. Dr Mood, Dr Kumbhani, and Dr Borek have no potential conflicts of interest that are directly relevant to the contents of this manuscript.

Author information

Correspondence to Dr Deepak L. Bhatt.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bavry, A.A., Mood, G.R., Kumbhani, D.J. et al. Long-Term Benefit of Statin Therapy Initiated during Hospitalization for an Acute Coronary Syndrome. Am J Cardiovasc Drugs 7, 135–141 (2007). https://doi.org/10.2165/00129784-200707020-00005

Download citation


  • Statin
  • Acute Coronary Syndrome
  • Pravastatin
  • Statin Therapy
  • Ezetimibe