Abstract

Aims To analyse (1) the prognostic importance of clinical findings and lipids in patients with a previous myocardial infarction and (2) the relative and absolute benefit of simvastatin in patients at low, medium and high predicted risk.

Methods The 4S was a double-blind, randomized, clinical trial of long-term treatment with simvastatin or matching placebo in patients with myocardial infarction or angina pectoris, serum total cholesterol 5·5–8·0mmol.l−1, and serum triglycerides ≤2·5mmol.l−1. The present study only deals with those 3525 patients who had a previous myocardial infarction. End-points comprised coronary death, definite and probable hospital verified myocardial infarction, and resuscitated cardiac arrest. Because there were few women the primary analyses were performed among men.

Results A Cox model analysis in the placebo group identified the following independent predictors of coronary events: a history of hypertension (P=0·023), diabetes (P=0·0001), smoking after the myocardial infarction (P=0·010), total cholesterol (P=0·020), and HDL cholesterol (P=0·062). The relative reduction of risk by simvastatin treatment in patients at low, medium and high predicted risk was 38%, 39% and 42%, respectively, but the corresponding absolute benefit per 100 patients treated for 6 years increased from 7·9 to 16·2.

Conclusion In addition to serum lipids, clinical variables contributed significantly to prediction. The relative benefit from simvastatin treatment was independent of predicted risk, but the absolute benefit increased from low to high risk.

f1
Correspondence: Professor Lars Wilhelmen, MD, PhD, Section of Preventive Cardiology, Göteburg University, Drakegatan 6, SE-412 50 Göteburg, Sweden.

References

1
Peterson
ED
, Shaw LJ, Califf RM. Clinical Guideline: Part II. Risk stratification after myocardial infarction.
Ann Intern Med
 .
1997
;
126
:
561
–582
2
Ulvenstam, G, Deaths and recurrences after myocardial infarction—occurrence and risk factors, Göteborg University, Göteborg, 1984
3
Haider
AW
, Davies GJ. Preinfarction angina as a major predictor of left ventricular function and long-term prognosis after a first Q wave myocardial infarction.
J Am Coll Cardiol
 .
1996
;
27
:
954
–955
4
Bigger
JT
Jr
, Fleiss JL, Kleiger R, Miller JP, Rolnitzky LM. The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction.
Circulation
 .
1984
;
69
:
250
–258
5
Ulvenstam
G
, Åberg A, Bergstrand R. Long-term prognosis after myocardial infarction in men with diabetes.
Diabetes
 .
1985
;
34
:
787
–792
6
Wong
ND
, Cupples LA, Ostfeld AM, Levy D, Kannel WB. Risk factors for long-term coronary prognosis after initial myocardial infarction: the Framingham Study.
Am J Epidemiol
 .
1989
;
130
:
469
–480
7
Behar
S
, Boyko V, Reicher-Reiss H, Goldbourt U. Ten-year survival after acute myocardial infarction: comparison of patients with and without diabetes. SPRINT Study Group, Secondary Prevention Reinfarction Israeli Nifedipine Trial.
Am Heart J
 .
1997
;
133
:
290
–296
8
Wilhelmsen
L
. Effects of cessation of smoking after myocardial infarction.
J Cardiovasc Risk
 .
1998
;
5
:
173
–176
9
Herlitz
J
, Bang A, Karlsson BW. Five-year prognosis after acute myocardial infarction in relation to a history of hypertension.
Am J Hypertens
 .
1996
;
9
:
70
–76
10
Gustafsson
F
, Køber L, Torp-Pedersen C, Hildebrandt P, Ottesen MM, Sonne B, Carlsen J. Long-term prognosis after acute myocardial infarction in patients with a history of arterial hypertension.
Eur Heart J
 .
1998
;
19
:
588
–594
11
Ulvenstam
G
, Bergstrand R, Johansson S. Prognostic importance of cholesterol levels after myocardial infarction.
Preventive Medicine
 .
1984
;
13
:
355
–366
12
Lancet
 .
1995
;
345
:
1274
–1275
13
Lancet
 .
1994
;
344
:
1383
–1389
14
Miettinen
TA
, Pyörälä K, Olsson AG. Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris: findings from the Scandinavian Simvastatin Survival Study (4S).
Circulation
 .
1997
;
96
:
4211
–4218
15
Berg
K
, Dahlen G, Christophersen B, Cook T, Kjekshus J, Pedersen T. Lp(a) lipoprotein level predicts survival and major coronary events in the Scandinavian Simvastatin Survival Study.
Clin Genet
 .
1997
;
52
:
254
–261
16
Pedersen
TR
, Olsson AG, Faergeman O. Lipoprotein changes and reduction in the incidence of major coronary heart disease events in the Scandinavian Simvastatin Survival Study (4S).
Circulation
 .
1998
;
97
:
1453
–1460
17
Pyörälä
K
, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease.
Diabetes Care
 .
1997
;
20
:
614
–620
18
Haffner
SM
, Alexander CM, Cook TJ. Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels: subgroup analyses in the Scandinavian Simvastatin Survival Study.
Arch Intern Med
 .
1999
;
159
:
2661
–2667
19
Pedersen
TR
, Berg K, Cook TJ. Safety and tolerability of cholesterol lowering with simvastatin during 5 years in the Scandinavian Simvastatin Survival Study.
Arch Intern Med
 .
1996
;
156
:
2085
–2092
20
D'Agostino
RB
, Russell MW, Huse DM. Primary and subsequent coronary risk appraisal: New results from the Framingham Study.
Am Heart J
 .
2000
;
139
:
272
–281
21
Eur Heart J
 .
1997
;
18
:
1569
–1582
22
Åberg
A
, Bergstrand R, Johansson S. Cessation of smoking after myocardial infarction. Effects on mortality after 10 years.
Br Heart J
 .
1983
;
49
:
416
–422
23
Hosoda
S
, Kimata S, Tamura K. Follow-up of 2,733 Japanese patients with myocardial infarction.
Jpn Circ J
 .
1995
;
59
:
121
–129
24
McCall
M
, Elmfeldt D, Vedin A, Wilhelmsson C, Wedel H, Wilhelmsen L. Influence of a myocardial infarction on blood pressure and serum cholesterol.
Acta Med Scand
 .
1979
;
206
:
477
–481
25
Hjalmarson
A
, Gilpin EA, Kjekshus J. Influence of heart rate on mortality after acute myocardial infarction.
Am J Cardiol
 .
1990
;
65
:
547
–553
26
Copie
X
, Hnatkova K, Staunton A, Fei L, Camm AJ, Malik M. Predictive power of increased heart rate versus depressed left ventricular ejection fraction and heart rate variability for risk stratification after myocardial infarction. Results of a two-year follow-up study.
J Am Coll Cardiol
 .
1996
;
27
:
270
–276
27
Dobson
AJ
, Evans A, Ferrario M. Changes in estimated coronary risk in the 1980s: data from 38 populations in the WHO MONICA Project.
Ann Med
 .
1998
;
30
:
199
–205
28
Rosengren
A
, Wilhelmsen L, Hagman M, Wedel H. Natural history of myocardial infarction and angina pectoris in a general population sample of middle-aged men: a 16 year follow-up of the Primary Prevention Study, Göteborg, Sweden.
J Intern Med
 .
1998
;
244
:
495
–505

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