ISCHAEMIC HEART DISEASE

PROVE-IT proves the obvious, but A-Z does not▸

PROVE-IT proved the benefits of atorvastatin 80 mg over pravastatin 40 mg. The Z phase of the A to Z trial randomised 4500 patients who had been admitted to hospital with acute coronary syndrome (ACS) to four months placebo, or 30 days of 40 mg of simvastatin followed by 80 mg for the remainder of a four month period. Following this initial period all patients were switched to 20 mg of simvastatin once a day. Surprisingly, the higher dose regimen failed to show a significant benefit on the primary end points of cardiovascular death, myocardial infarction (MI), re-admission for ACS or stroke at four months (hazard ratio 0.89, 95% CI 0.76 to 1.04; p  =  0.14), although there was some later benefit from aggressive treatment. Furthermore, side effects were particularly problematic; nine patients developed myopathy and there were three cases of frank rhabdomyolysis. In both the A to Z and MIRACL trials the reduction in low density lipoprotein (LDL) concentrations were 1.6 mmol/l, but whereas MIRACL confirmed the benefit of 80 mg atorvastatin in the first four months after an ACS, A to Z showed no such benefit with 80 mg of simvastatin. One noticeable difference between A to Z and the MIRACL and PROVE-IT studies was that A to Z showed a much smaller decrease in mean C reactive protein concentrations in the treated group (16.7% v 34%), perhaps indicating that the anti-inflammatory role of statins may be the crucial therapeutic mechanism in the early stages after an ACS.

Lyse then stent acute MI▸

In patients with ST segment elevated myocardial infarction (STEMI), early post-thrombolysis routine angioplasty has been discouraged because of its association with high incidence of events. The GRACIA-1 trial was designed to reassess the benefits of an early post-thrombolysis interventional approach in the era of stents and new antiplatelet agents. All …