Statins and cardiovascular disease—major therapeutic advances but are we seizing the moment?

acute cardiac events. So patients with coronary disease, and those at even moderate risk of future development of such disease benefit significantly from statin therapy. Now it is also looking as if there is a significant reduction in non-haemorrhagic stroke with long-term statin treatment in patients with coronary disease. Combining the 13 000 patients from CARE and LIPID, there was a 22% reduction in total strokes, and a 25% reduction in non-fatal strokes. In this edition, Wilhelmsen and his colleagues from the 4S study group have, using their excellent database, looked at the risk factors that play a part in subsequent major coronary events in those with prior myocardial infarction, and assessed the impact of predicted risk on the benefit of cholesterol-lowering treatment. The majority of patients in the 4S study had been included in the stable phase following myocardial infarction, and thus, the present report, analysing 3525 patients, would not be expected to come up with very different prognostic findings from the cholesterol reduction viewpoint, as it includes approximately 78% of the original cohort. With regard to risk factors, those with a longer period between myocardial infarction and subsequent randomization to 4S had the highest subsequent end-point incidence, and subsequent events were more common in those with more than one infarction prior to inclusion, in those with hypertension, in those who continued to smoke following their index myocardial infarction, and in diabetics. Presumably many of these risk factors were in play prior to the time of the index infarction which made these patients suitable for the 4S trial in the first place, and thus it is not surprising that they continue to be so following such an index event. The authors found that, while there was no difference in the relative benefit from simvastatin in those post-infarction patients at low, medium, and high risk, the absolute benefit of simvastatin treatment doubled from the lowest to the highest tertile of risk. This latter finding reflects a likely important interplay between cholesterol and other recognized risk factors such as smoking, hypertension, and diabetes, and may help us when considering who to treat particularly amongst ‘normal’ populations. It is likely that treatment benefit will be greater in those with an elevated cholesterol/LDL-C in association with other See page 1119 for the article to which this Editorial refers