Postdischarge lipid management of coronary artery disease patients according to the new National Cholesterol Education Program guidelines.

The highest risk of a recurrent event in patients with acute coronary syndromes (ACS) occurs in the first month, with the rates of reported events ranging from 10% to 25%. Statins are the cornerstone of lipid-lowering therapy for the long-term care of patients with stable atherosclerotic disease. More recent accumulated data from several trials now show that statin therapy can also help reduce cardiovascular risk in unstable disease. These studies evaluated the effects of statin therapy begun before discharge, with the Myocardial Ischemia with Aggressive Cholesterol Lowering (MIRACL) trial showing that therapy could be started as early as 24 hours after onset with measurable clinical benefit. Registry data also suggest that long-term compliance may be improved in patients with a predischarge statin prescription compared with a postdischarge statin prescription. This is because many patients discharged without a statin prescription are either lost to further medical follow-up or do not receive a statin prescription from their primary care provider. The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III), which constitutes the updated clinical guidelines of the National Cholesterol Education Program (NCEP), recommends that lipid-lowering drug therapy be initiated at hospital discharge. ATP III also provides important information on the goals of lipid-lowering therapy in patients after ACS. The challenge for the specialist is to establish a predischarge plan that includes maximal dosing to achieve aggressive target goals and to work with the patient's primary care provider to maintain these goals long-term.