European Heart Journal Advance Access originally published online on July 29, 2008
European Heart Journal 2008 29(17):2083-2091; doi:10.1093/eurheartj/ehn346
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Discontinuation of statin therapy following an acute myocardial infarction: a population-based study
1 Division of Internal Medicine, Department of Medicine, McGill University, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, B2.236, Montreal, QC, Canada H3G 1A4
2 Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada
3 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
4 Department of Biostatistics, University of Washington, Seattle, WA, United States of America
5 Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
Received 21 January 2008; revised 8 July 2008; accepted 11 July 2008; online publish-ahead-of-print 29 July 2008.
* Corresponding author. Tel: +1 514 934 1934 ext. 42295, Fax: +1 514 934 8573. Email: stella.daskalopoulou{at}mcgill.ca
See page 2061 for the editorial comment on this article (doi:10.1093/eurheartj/ehn348)
Aims: Randomized clinical trials have shown that statins can reduce mortality after acute myocardial infarction (AMI). However, the impact of changes in patterns of statin use, particularly stopping statins, on survival post-AMI is unknown. Our objective was to estimate the extent to which different patterns of statin use are associated with post-AMI mortality.
Methods and results: Population-based, cohort study, from 2002 through 2004 in the United Kingdom General Practice Research Database (GPRD), involving patients surviving 90 days after their first AMI. Past statin use was defined as any statin prescription within 90 days before AMI; statin use post-AMI as any statin prescription within 90 days after AMI. Cohort entry was at day 90 post-AMI; subjects were followed for 1 year. Four groups were identified: (i) non-users (patients never on statins); (ii) users (on statins before and continued post-AMI); (iii) starters (started statins after the event); and (iv) stoppers (stopped statins after the event). Hazard ratios (HRs) were estimated using Cox proportional hazards model. The main outcome measure was 1-year all-cause mortality. The cohort included 9939 AMI survivors (mean age: 68.4 ± 12.8 years; 60.3% men), 22.7% of whom were not prescribed a statin post-AMI. When the non-user group (n = 2124) was considered as the reference, the adjusted HRs (95% confidence intervals) of death were 0.84 (0.66–1.09) for users (n = 2026), 0.72 (0.57–0.90) for starters (n = 5652), and 1.88 (1.13–3.07) for stoppers (n = 137). Stoppers of control medications (aspirin, β-blockers, and proton pump inhibitors) were not associated with increased mortality.
Conclusion: Discontinuation of statins in survivors of a first AMI was relatively rare in this cohort. However, statin discontinuation was associated with higher total mortality and this may represent a biological rebound or/and a risk-treatment mismatch phenomenon, where treatment is withdrawn from very ill patients. While awaiting further research, at present statin use should only be withdrawn under judicious clinical supervision.
Key Words: Acute myocardial infarction • Statins • Discontinuation • Biological rebound phenomenon • Risk-treatment mismatch • General Practice Research Database
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EHJ 2008 29: 2061-2063.[Extract] [Full Text]