Strategies to increase HMG-CoA reductase inhibitor use after acute myocardial infarction.

Coronary artery disease with its accompanying complication of acute myocardial infarction (MI) is one of the major causes of death in the modern world. A variety of both primary and secondary prevention strategies have been developed for the treatment of acute MI. One of the more important of these strategies is the prescription of HMG-CoA reductase inhibitors. HMG-CoA reductase inhibitors have the potential to positively affect the outcome of acute MI in a variety of ways including the reduction of low-density lipoprotein-cholesterol levels and stabilisation of the atherosclerotic plaque. Multiple large randomised clinical trials have documented the potential of HMG-CoA reductase inhibitors to reduce both short- and long-term mortality after acute MI. This benefit exists regardless of age, gender, clinical presentation, or even baseline lipid levels. However, despite this overwhelming amount of evidence supporting the use of HMG-CoA reductase inhibitors in the post-MI setting, multiple studies have documented the presence of a significant 'treatment gap'. Indeed, often, less than half of acute MI patients who would benefit from HMG-CoA reductase inhibitor therapy actually receive it. The reasons for the low utilisation of HMG-CoA reductase inhibitors in the acute MI patient are many, but may include poor communication, the high cost of treatment, the lack of associated symptoms and confusion regarding appropriate lipid levels to target. One approach that has been tried to address these issues is the development of institutional programmes specifically targeted to increase the use of HMG-CoA reductase inhibitors in acute MI patients. These programmes, often managed by nurses or pharmacists, have been piloted in several institutions. They have been effectively implemented in both inpatient and outpatient settings. In most cases they have been implemented without a great increase in expense. They have often increased the use of HMG-CoA reductase inhibitors to >90%. Most importantly, they have documented a significant improvement in the long-term survival of acute MI patients. Based on these preliminary studies, it is recommended that the implementation of these strategies be considered by most healthcare institutions.