What are the statin (HMG-CoA reductase inhibitor) guidelines for patients with a history of myocardial infarction (MI)?

From the Guidelines

Patients with a history of myocardial infarction should be prescribed high-intensity statin therapy indefinitely as secondary prevention, with a goal to reduce LDL cholesterol by < 55 mg/dL (< 1.4 mmol/L), as recommended by the most recent guidelines 1.

Statin Therapy Guidelines

The guidelines for statin therapy in patients with a history of myocardial infarction (MI) are based on the latest evidence from clinical trials and expert consensus.

• High-intensity statins, such as atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily, are recommended for most patients with a history of MI, as they have been shown to reduce the risk of recurrent cardiovascular events, including repeat MI, stroke, and cardiovascular death 1.
• Moderate-intensity options, such as atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, or pravastatin 40-80 mg daily, may be considered for patients who cannot tolerate high-intensity therapy due to side effects or are at increased risk for adverse events 1.

Treatment Initiation and Monitoring

• Treatment with high-intensity statin therapy should begin during hospitalization for MI and continue long-term, with regular monitoring of liver function tests and creatine kinase, especially if muscle symptoms develop 1.
• Lifestyle modifications, including a heart-healthy diet, regular exercise, smoking cessation, and weight management, should accompany statin therapy for optimal outcomes 1.

LDL-Cholesterol Targets

• The goal of statin therapy is to reduce LDL cholesterol by < 55 mg/dL (< 1.4 mmol/L), which can be achieved by taking the highest possible doses of potent statins, such as atorvastatin or rosuvastatin, or by adding ezetimibe or a proprotein convertase subtilisin/kexin type 9 protein inhibitor (PCSK9 inhibitor) to the treatment regimen 1.
• If the LDL-C level is above 55 mg/dL (1.4 mmol/L) after 4-6 weeks of treatment, ezetimibe should be added to the statin therapy, and if the LDL-C level is still not below 55 mg/dL (1.4 mmol/L) after another 4-6 weeks, a PCSK9 inhibitor should be added to the treatment regimen 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD MI and stroke in adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD. Non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure, and angina in adults with clinically evident CHD.

The statin guidelines for patients with a history of myocardial infarction (MI) are to reduce the risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure, and angina in adults with clinically evident coronary heart disease (CHD) 2.

• The recommended starting dosage is 10 or 20 mg once daily; dosage range is 10 mg to 80 mg once daily for adults 2.
• Patients requiring LDL-C reduction >45% may start at 40 mg once daily 2.
• It is essential to assess LDL-C when clinically appropriate, as early as 4 weeks after initiating atorvastatin calcium, and adjust dosage if necessary 2.

From the Research

Statin Guidelines for Patients with a History of Myocardial Infarction (MI)

The guidelines for statin (HMG-CoA reductase inhibitor) therapy in patients with a history of myocardial infarction (MI) are based on several studies that have investigated the effectiveness of different statin dosing regimens in reducing the risk of recurrent cardiovascular events.

• The 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidemia guidelines recommend a low-density lipoprotein cholesterol (LDL-C) target of < 55 mg/dL for patients with a history of MI 3.
• A study published in the Journal of Clinical Medicine found that a short-course high-intensity statin treatment during admission for MI could rapidly reduce LDL-C levels, and that most patients would theoretically achieve an LDL-C < 55 mg/dL with discharge lipid-lowering therapy (LLT) if LDL-C during admission was used as the reference value 4.
• Another study published in the Revista de Investigacion Clinica found that only 18.2% of patients with a history of MI achieved the LDL-C target of < 55 mg/dL, and that the use of high-intensity statin therapy was associated with a higher rate of LDL-C target attainment 3.
• The American College of Cardiology/American Heart Association guidelines recommend high-intensity statin therapy for patients after MI, rather than treating to a specific LDL-C goal 5.
• A study published in the European Heart Journal found that higher initial statin dose after MI was associated with better long-term cardiovascular outcomes, including a reduced risk of major adverse cardiovascular or cerebrovascular events (MACCE) 6.
• Another study published in Cardiovascular Drugs and Therapy found that only 37.7% of patients with diabetes mellitus (DM) and 44.4% of patients without DM titrated to a high-intensity statin dosage following an AMI hospitalization 7.

Key Findings

• High-intensity statin therapy is recommended for patients with a history of MI to reduce the risk of recurrent cardiovascular events.
• The LDL-C target for patients with a history of MI is < 55 mg/dL, according to the 2019 ESC/EAS dyslipidemia guidelines.
• Higher initial statin dose after MI is associated with better long-term cardiovascular outcomes.
• The use of high-intensity statin therapy is associated with a higher rate of LDL-C target attainment.
• Most patients taking a low/moderate-intensity statin are not titrated to a high-intensity dosage following AMI, potentially leaving substantial residual risk for recurrent cardiovascular events.