Abstract
The Myocardial Ischemia Reduction with Acute Cholesterol Lowering (MIRACL) Trial tested the hypothesis that intensive lowering of cholesterol with atorvastatin (80 mg/day) initiated 24-96 h after an acute coronary syndrome would, over 4 months, reduce the incidence of the composite endpoint of death, nonfatal infarction, resuscitated cardiac arrest, and recurrent symptomatic myocardial ischemia with new objective symptoms requiring emergency rehospitalization. This primary composite endpoint was reduced from 17.4% to 14.8% (P = 0.048) among the 3086 patients enrolled. The results of MIRACL suggest that patients with acute coronary syndromes should begin to receive this treatment before leaving hospital, irrespective of baseline levels of low-density lipoprotein-cholesterol.
Highlights
This ‘knowledge gap’ has perhaps contributed to a ‘treatment gap’
Recent evidence suggests that lowering low-density lipoprotein (LDL)-cholesterol favorably influences pathophysiological mechanisms that may be intimately involved in the genesis of acute coronary syndromes [3,4,5]
Cholesterol lowering normalizes the tendency to increase the deposition of platelet thrombus, a LDL = low-density lipoprotein; MIRACL Trial = Myocardial Ischemia Reduction with Acute Cholesterol Lowering Trial
Summary
At 122 sites in 19 countries, 3086 patients with unstable angina or non-Q-wave infarction were randomized to placebo or to atorvastatin (80 mg/day) within 24–96 hours of admission to hospital [6,7]. The primary, predefined endpoint was the time to death, myocardial infarction, resuscitated cardiac arrest, or worsening angina with new objective evidence of myocardial ischemia requiring urgent rehospitalization. This composite endpoint was reduced from 17.4% to 14.8%, a relative reduction of 16% (P = 0.048). For approximately $500 in drug costs per patient, the event rate during 4 months of treatment was reduced by 2.6%, a cost:benefit ratio that compared favorably with that seen in long-term secondary prevention with statins [8]. Like all innovative clinical trials, MIRACL raises many interesting questions, some of which will be discussed here
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