NICE guidance - statin treatment post myocardial infarction (MI)

Some summary points from NICE guidance concerning use of statin treatment post myocardial infarction (1):

• statin therapy is recommended for adults with clinical evidence of cardiovascular disease
• after an MI, all patients should be offered treatment with a statin as soon as possible
• decision whether to initiate statin therapy should be made after an informed discussion between the healthcare professional and the individual about the risks and benefits of statin treatment, and taking into account additional factors such as comorbidities and life expectancy
• baseline liver enzymes should be measured before initiation of a statin.
• patients who have raised liver enzymes should not routinely be excluded from statin therapy
• patients who are intolerant of statins should be considered for other lipid lowering agents
• routine monitoring of creatine kinase in asymptomatic patients who are being treated with a statin after an MI is not recommended
• patients who are being treated with a statin and who develop muscle symptoms (pain, tenderness or weakness) should be advised to seek medical advice so that creatine kinase can be measured
• dose of any statin may need to be reduced or stopped if there are issues surrounding the metabolic pathway, food and/or drug interactions and/or concomitant illness
• statins should be discontinued in patients who develop peripheral neuropathy that may be attributable to the statin treatment, and further advice from a specialist should be sought.

Statins for secondary prevention (2):

• statin therapy is recommended for adults with clinical evidence of CVD
• decision whether to initiate stain therapy should be made after an informed discussion between the responsible clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as comorbidities and life expectancy
• when decision has been made to prescribe a statin
  • recommended that therapy should usually be initiated with a drug with a low acquisition cost (taking into account required daily dose and product price per dose)
  • people with acute coronary syndrome should be treated with a higher intensity statin . Any decision to offer a higher intensity statin should take into account the patient's informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment
  • treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen
  • in people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment
    • 'audit' level of total cholesterol of 5 mmol/litre should be used to assess progress in populations or groups of people with CVD, in recognition that more than a half of patients will not achieve a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre

For full details then consult full guidelines (1,2).

Reference:

• (1)NICE (May 2007). Secondary prevention in primary and secondary care for patients following a myocardial infarction
• (2)NICE (May 2008).Lipid modification - Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease