Division of Internal Medicine, Department of Medicine, McGill University, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, B2.236, Montreal, QC, Canada.
Eur Heart J. 2008 Sep;29(17):2083-91. doi: 10.1093/eurheartj/ehn346. Epub 2008 Jul 29.
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.
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.
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mortality and this may represent a biological rebound or/and a risk-treatment mismatch phenomenon, where treatment is withdrawn from very ill patients. While awaiting further research, at present statin use should only be withdrawn under judicious clinical supervision.
随机临床试验表明，他汀类药物可降低急性心肌梗死（AMI）后的死亡率。然而，他汀类药物使用模式的变化，尤其是停止使用他汀类药物，对 AMI 后生存的影响尚不清楚。我们的目的是评估不同的他汀类药物使用模式与 AMI 后死亡率之间的关系。
这是一项基于人群的队列研究，来自英国全科医生研究数据库（GPRD），于 2002 年至 2004 年进行，涉及首次 AMI 后存活 90 天的患者。既往他汀类药物使用定义为 AMI 前 90 天内的任何他汀类药物处方；AMI 后他汀类药物使用定义为 AMI 后 90 天内的任何他汀类药物处方。队列纳入时间为 AMI 后第 90 天；随访 1 年。确定了 4 个组：（i）非使用者（从未使用过他汀类药物的患者）；（ii）使用者（AMI 前使用他汀类药物并继续使用）；（iii）起始使用者（AMI 后开始使用他汀类药物）；（iv）停药者（AMI 后停止使用他汀类药物）。使用 Cox 比例风险模型估计风险比（HRs）。主要观察指标为 1 年全因死亡率。该队列包括 9939 名 AMI 幸存者（平均年龄：68.4±12.8 岁；60.3%为男性），其中 22.7%的患者未在 AMI 后开他汀类药物处方。将非使用者组（n=2124）作为参考时，死亡的调整 HR（95%置信区间）分别为使用者（n=2026）0.84（0.66-1.09）、起始使用者（n=5652）0.72（0.57-0.90）和停药者（n=137）1.88（1.13-3.07）。停止使用控制药物（阿司匹林、β受体阻滞剂和质子泵抑制剂）与死亡率增加无关。
在该队列中，首次 AMI 幸存者中停用他汀类药物的情况相对较少。然而，他汀类药物的停药与总死亡率的增加有关，这可能代表一种生物学反弹或/和风险-治疗不匹配现象，即病情严重的患者停止了治疗。在等待进一步研究的同时，目前只有在谨慎的临床监督下才能停用他汀类药物。
