Loading of High Dose Atorvastatin Prior to PCI in Acute Coronary Syndrome
PracticeUpdate: Could you please provide a brief overview of the results of the SECURE-PCI trial?
Dr. Bhatt: Secure PCI examined patients and randomized them to pretreatment with statins or not. The trial results were very interesting. Overall, there wasn’t a significant benefit, so some might say stop right there, it's a negative study, but in fact, if one examines the patients who actually underwent PCI, in particular, those with an MI undergoing PCI, there, there did seem to be some benefit of a strategy of high loading doses of atorvastatin peri-PCI.
I'm not sure what the practical ramifications of the study would be. I do think it's probably a good idea to get a loading dose of a statin onboard in patients who were statin naive that come in with an acute coronary syndrome and/or are undergoing PCI because all those patients likely should be on a statin anyway, so I don’t see any harm in getting that loading dose onboard or that initial high dose onboard prior to their procedure, for example, and it appears there might be some benefit from this trial. In a number of random smaller studies that were randomized in the past showed benefit, and a number of large observational analyses from the past also showed benefit, so the majority of the data out there support at least neutrality and potential benefit of a therapy that we would be using anyway, that is starting statins on patients who need them, so I think the results are useful in that regard, and I think I would keep doing what I'm doing right now, which is making sure patients who should be on statins such as those with ACS or undergoing PCI are on statins and I would start it sooner rather than later.
PracticeUpdate: Based on the results of the ODYSSEY and SECURE-PCI trial, what do you see as the optimal treatment strategy for patients with coronary artery disease undergoing PCI?
Dr. Bhatt: In patients undergoing PCI, obviously, they have coronary artery disease severe enough to warrant PCI, there I think getting their LDL cholesterol as low as possible is a good goal. I would do that with high potency statins, atorvastatin 80 mg, rosuvastatin 20 or 40 mg, and if that doesn’t do the trick, likely add ezetimibe 10 mg a day. If those sorts of patients still have a very high LDL cholesterol, and by that, I mean greater than or equal to 100, and if they’d had an acute coronary syndrome, based on the ODYSSEY trial, I would likely go ahead then and add a PCSK9 inhibitor. I probably wouldn't do that during that index hospital admission even though that might be the right thing to do, but that’s not what we tested in ODYSSEY, so I would likely do what was done in the trial, start it 1 to 12 months after the ACS, but within that time window, probably better to do it sooner, so I would rather see them at a month, and if they're already maxed out on a statin and ezetimibe, add the PCSK9 inhibitor then.
Click on any of these tags to subscribe to Topic Alerts. Once subscribed, you can get a single, daily email any time PracticeUpdate publishes content on the topics that interest you.
Visit your Preferences and Settings section to Manage All Topic Alerts
Additional Info
Disclosure statements are available on the authors' profiles: