Liều nạp statin trong hội chứng vành cấp có thực sự đem lại lợi ích ngắn hạn và dài hạn

Cholesterol Management Class I High-intensity statin therapy should be initiated or continued in all patients with NSTE-ACS and no contraindications to its use.. Lipid Management: Rec

Dinh Duc Huy, MD, FSCAI Tam Duc Heart Hospital

High dose statin loading in ACS– short & long term outcomes benefit

Cholesterol Management

Class I

High-intensity statin therapy should be initiated or

continued in all patients with NSTE-ACS and no

contraindications to its use (Level of Evidence: A)

Class IIa

It is reasonable to obtain a fasting lipid profile in patients with NSTE-ACS, preferably within 24 hours of presentation

(Level of Evidence: C)

2014 AHA/ACC Guideline for the Management of

Patients With Non–ST-Elevation ACS

Lipid Management: Recommendations

CLASS I

High-intensity statin therapy should be initiated or

continued in all patients with STEMI and no contraindications

to its use (Level of Evidence: B)

CLASS IIa

It is reasonable to obtain a fasting lipid profile in patients with

STEMI, preferably within 24 hours of presentation (Level of

Evidence: C)

2013 ACCF/AHA Guideline for the Management of

ST-Elevation Myocardial Infarction

Coronary angiography

Placebo

12 hrs pre-angio;

further dose 2 hrs before N=95

Primary combined end point: 30-day death, MI, TVR

1 st blood sample (pre-PCI)

CK-MB, troponin-I, myoglobin, CRP

ARMYDA-ACS trial: Study design

2 nd and 3 rd blood samples (8 and 24 hrs post-PCI)

PCI placebo N=85

20 pts excluded for indication to:

Individual and Combined Outcome Measures

of the Primary End Point at 30 days

13/85 (15%)

1/85 (2%)

14/85 (17%)

4/86 (5%)

%

Composite Primary End Point

Patti G, J Am Coll Cardiol 2007 Mar 27;49(12):1272-8

ARMYDA-ACS: CONCLUSIONS

1 Even a short-term atorvastatin pretreatment prior to PCI

may improve outcome in patients with Unstable Angina and

NSTEMI; mostly driven by a reduction of peri-procedural MI

(70% risk reduction)

2 Lipid-independent pleiotropic actions of atorvastatin may

explain such effect

3 These findings may support the indication of “upstream”

administration of high dose statins in patients with Acute

Coronary Syndromes treated with early invasive strategy

Patti G, J Am Coll Cardiol 2007 Mar 27;49(12):1272-8

Individual and Combined Outcome Measures

of the Primary Endpoint at 30 days

P=0.045

%

Composite Primary End Point

MI TVR MACE

Atorvastatin Placebo

3.4

Di Sciasio G J Am Coll Cardiol 2009 Aug 4;54(6):558-65

The primary end point was 30-days composite primary end point of death,

myocardial infarction, and target vessel revascularization

15.9

0 2 4 6 8 10 12 14 16 18

• 445 ACS patients who underwent PCI

• Control group (n=220, 63±11 years,

male 62%)

• Statin group of 40 mg rosuvastatin

loading before PCI (n=225, 64±10

years, male 60%)

• Incidence of peri-procedural

myocardial injury was assessed by

analysis of CK-MB & cardiac troponin T

before PCI, at 6 h and the next

morning after PCI

12-month follow-up results of high dose rosuvastatin

loading before PCI in patients with ACS

Methods:

MACE including cardiac death, non-fatal MI, non-fatal stroke, & any

ischemia-driven revascularization, was assessed after 12 months

Results:

• In 11±3 months of follow-up, MACE occurred in 20.5% of patients

in control group vs 9.8% in rosuvastatin group (p=0.002)

• The incidence of death and non-fatal MI was significantly greater

in control group than in rosuvastatin group (p=0.021)

• Multivariate analysis revealed that rosuvastatin loading was an

independent predictor of a reduction in the risk of MACE at 12

months (p=0.006)

Yun KH, et al, Int J Cardiol (2010), doi:10.1016/j.ijcard.2010.04.052

Yun KH, et al, Int J Cardiol (2010), doi:10.1016/j.ijcard.2010.04.052

12- month MACE in patients with ACS who received

no rosuvastatin or high dose rosuvastatin loading before PCI

To compare a reloading dose of Rosuvastatin 40mg and

Atorvastatin (80mg) administered within 24h before the procedure

in reducing the rate of periprocedural myonecrosis (CKMB>3ULN)

in patients on chronic statin treatment

CK-MB

MACE

ACSIS study - STATINS LOADING BEFORE PPCI

did not receive a

statin before PPCI

Early statin loading was associated with more frequent early STR > 70% (81% vs 67, p= 0.005)

Statin loading prior to PPCI remained independent predictor of early STR (OR 2.97, CI 1.62-5.45,

p=0.00005) in multivariable analysis

Diego Medvedofsky J Am Coll Cardiol 2013;61(10_S): doi:10.1016/S0735 1097(13)60066-2

Young-Guk Ko, Am J Cardiol 2014;114:29-35

1 Serial MRI data were available for 121 patients

2 The relative infarct volumes in the acute and chronic phases

were not different between the groups

3 No differences between groups were observed for peri-procedural

micro-vascular circulation evaluated by TIMI flow grade,

myocardial blush grade, ST-segment resolution, micro-vascular

obstruction on cardiac MRI, or clinical outcomes

4 Early high-dose rosuvastatin therapy in patients with STEMI

undergoing PPCI did not improve peri-procedural myocardial

perfusion or reduce infarct volume measured by MRI compared

with the conventional low-dose rosuvastatin regimen

ROSEMARY study main findings

Young-Guk Ko, Am J Cardiol 2014;114:29-35

Alexandre M Benjo, Catheterization and Cardiovascular Interventions 85:53–60 (2015)

Evaluate the incidence of peri-procedure MI and MACE including

spontaneous MI, death, and TVR of statin nạve patients presenting with stable angina or NSTE-ACS and treated with statins prior to PCI

High dose statin therapy given prior to PCI in patients with NSTE-ACS is associated with a

reduction in pMI and short-term clinical events

Alexandre M Benjo, Catheterization and Cardiovascular Interventions 85:53–60 (2015)

• 1,591 patients were given loading dose of

statin before PCI

• 1,555 patients were given statin therapy

initiated only after the PCI

• Statin loading prior to PCI was associated

with a 56% RR in pMI (OR: 0.44,

P<0.00001)

treated with statin loading prior to PCI

(OR: 0.59, P=0.02)

• Results were only significant for those

P=0.0005) and was not noted in the group

of patients who underwent PCI for stable

High-dose RSV preloading significantly improve myocardial perfusion

& reduce 58% MACE (P < 0.00001), 60% PMI (P < 0.0001)

in patients undergoing PCI

Not only stable angina and ACS patients but also statin nạve and

previous statin therapy patients

IBIS-4 study: High-intensity rosuvastatin therapy over 13 months is associated with regression of coronary atherosclerosis in non-infarct- related arteries among STEMI patients

-

-Raber L, et al European Heart Journal 2014; 1-11 doi:10.1093/eurheartj/ehu373

Lumen Area

Plaque Area

Baseline

Plaque Area

Lumen Area

Follow up

Rosuva 40mg

Thể tích mảng XV toàn bộ đoạn khảo sát

Intravascular Ultrasound-Derived Measures of Coronary Atherosclerotic Plaque Burden and Clinical Outcome

Nicholls SJ, et al J Am Coll Cardiol 2010;55:2399–407

A direct relationship was observed between the burden of coronary atherosclerosis, its progression, and adverse cardiovascular events

Statin-naive & Early Invasive Strategy NSTE-ACS patients

Coronary Angiography ± PCI

Hydration, N-Acetylcystein

Early high-dose Rosuvastatin for CIN Prevention in ACS

The PRATO-ACS study design

PRATO-ACS: CI-AKI Primary Endpoint

& Adverse Clinical Events (30 days)

J Am Coll Cardiol 2014;Jan 7-14;63(1):71-9

Conclusions

1 All those evidences strongly supports an ‘upstream’ administration

of high-dose statins (atorvastatin 80 mg/ rosuvastatin 40 mg

loading) in patients with ACS , especially to whom with an early

invasive strategy

2 Not only statin nạve and but also previous statin therapy patients can get benefit from this treatment

3 High dose statin loading can help improve both short and long

term outcomes for NSTE-ACS patients (less MACE- cardiac death,

MI, TVR)

4 High-dose rosuvastatin given on admission to statin-nạve patients who are scheduled for an early invasive strategy may help to

prevent CI-AKI