Pharmacologic Therapy

The use of aspirin at a dose of 81 to 150 mg per day reduces cardiovascular morbidity and mortality by 20 to 25 percent among patients with coronary artery disease. The results of several large, randomized trials indicate that the use of statins reduces the rate of coronary events and mortality in patients with established coronary artery disease and hyperlipidemia by 25 to 35 percent. Furthermore, a 25 to 30 percent reduction in revascularization rates in the large statin trials suggests a decrease in angina during the trials.

A recent trial involving patients with stable coronary artery disease demonstrated that treatment with 80 mg of atorvastatin daily slowed the progression of coronary atherosclerosis, as measured by intravascular ultrasound, over a period of 18 months, as compared with treatment with 40 mg of pravastatin daily. In another trial (the PROVE-IT-TIMI 22 [Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 study), the reduction of low-density lipoprotein (LDL) cholesterol levels to a mean of 62 mg per deciliter (1.6 mmol per liter) decreased the number of clinical events further than did a lesser reduction (to 95 mg per deciliter [2.5 mmol per liter]) in subjects with acute coronary ischemia. A recent trial likewise showed a significantly lower rate of cardiovascular events among patients with stable coronary disease who were treated with 80 mg of atorvastatin daily (achieved mean LDL cholesterol, 77 mg per deciliter [2.0 mmol per liter]) than among those treated with 10 mg daily; persistent elevations in aminotransferase levels complicated therapy in 1.2 percent of patients in the high-dose group, as compared with 0.2 percent of those in the low-dose group. The Adult Treatment Panel III of the National Cholesterol Education Program recently recommended target LDL cholesterol levels of 60 to 70 mg per deciliter (1.6 to 1.8 mmol per liter) in high-risk patients with coronary artery disease.

Statins reduce the levels of C-reactive protein, and two recent studies suggest that lowering these levels is as important as decreasing LDL cholesterol levels for the optimal reduction of coronary events. Angiotensin-converting-enzyme (ACE) inhibitors have been reported to reduce morbidity and mortality among patients with coronary disease, although the recent PEACE Trial (Prevention of Events with Angiotensin Converting Enzyme Inhibition Trial) did not confirm these findings, possibly owing to the relatively low risk among patients in this trial as compared with those in the HOPE trial (Heart Outcomes Prevention Evaluation study) and the EUROPA study (European Trial on Reduction of Cardiac Events with Perindopril in Stable coronary artery disease). ACE inhibitors should be prescribed for patients with chronic stable angina who have a history of myocardial infarction, hypertension, left ventricular systolic dysfunction, or Diabetes, as well as for patients with impaired renal function who do not have a contraindication to the use of these agents.