As the title indicates, Drs. Kumar and Cannon present a comprehensive review of the role of statins in acute coronary syndrome (ACS) – and then some. In fact, they present a discussion of the data accumulated in statin trials involving both unstable and stable coronary disease.
These data paint a bright and encouraging picture of a successful scientific process. Almost all these trials were products of collaboration between industry and academia. They illustrate that while clinical trials are usually the last step in confirming a clinical benefit, their results can sometimes cause us to reexamine the premises on which they are based. The rapid onset of benefits with statin interventions was one element that stimulated the reexamination of the fundamental pathophysiology of atherogenesis. As a result, the acute nature of plaque rupture and thrombotic occlusion, the central (and perhaps causative) role of inflammation, and the possibility that at least part of the statin benefit might be achieved exclusive of direct low density lipoprotein (LDL) lowering have all become the focus of concentrated scientific examination.
Sorting out these statin effects continues, but the rather unexpected benefit of statins on acute coronary syndrome has lent support to several new hypotheses, including (1) that lowering LDL has immediate benefits that were previously unappreciated; (2) that statins have significant antiatherogenic effects independent of LDL effects; (3) that an underlying inflammatory state is present in patients who are susceptible to acute atherosclerotic changes and (4) that some combination of all of these is at work in ACS and its response to statin interventions. In some discussions, the notion appears that multiple effects of statins must somehow be reduced to winners and losers, i.e., if the benefits are due to LDL, then inflammation plays no role – or vice-versa. In truth, it is likely that these effects are closely related and probably even inseparable.
Definitive answers to these questions remain to be uncovered. Drs. Kumar and Cannon, however, provide a helpful summary of progress to date and a clear guidepost to some of the directions that future research must take.