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Use of the Statins in Patients After Acute Myocardial Infarction
Does Evidence Change Practice?
Cynthia A. Jackevicius, BScPhm, MSc;
Geoffrey M. Anderson, MD, PhD;
Lawrence Leiter, MD;
Jack V. Tu, MD, PhD
Arch Intern Med. 2001;161:183-188.
Objective To compare the use of lipid-lowering agents in 42 628 elderly patients
(aged  65 years) after acute myocardial infarction, before and after the
publication of the Scandinavian Simvastatin Survival Study (4S), using the
Ontario Myocardial Infarction Database.
Methods Multivariate regression models were created to estimate changes in the
rate of statin use over time in monthly cohorts of elderly patients after
acute myocardial infarction in Ontario from April 1, 1992, to March 31, 1997.
Changes in the rate of statin use over time were estimated using patient and
prescriber characteristics.
Results We found a 3.6-fold significant increase in the monthly rate of statin
use after the publication of 4S compared with before the publication of 4S
(P<.001); specifically, the rate of increase in
simvastatin and pravastatin sodium use was higher after the publication of
4S (P<.001 for each). Before the publication of
4S, the rate of increase in statin use in younger patients (aged 65-74 years)
was 2.7 times higher than in older patients (aged 75 years) (P = .02), while after the publication of 4S, the rate of increase in
statin use was only 1.8-fold higher in the younger group (P<.001). After the publication of 4S, there was a 1.6-fold higher
rate of increase in statin use in male compared with female patients (P = .006). Also after the publication of 4S, specialists
(cardiologists and internists) had a 2-fold higher rate of increased use of
the statins than did generalists (P<.001).
Conclusion It is possible to shift practice if the evidence of benefit is strong,
the intervention is easy to implement, and the intervention is marketed aggressively.
From the Pharmacy Department, University Health Network–Toronto
General Hospital (Ms Jackevicius), the Departments of Health Administration
(Ms Jackevicius and Drs Anderson and Tu), Medicine (Drs Leiter and Tu), Nutritional
Sciences (Dr Leiter), and Public Health Sciences (Dr Tu), University of Toronto,
the Institute for Clinical Evaluative Sciences (Drs Anderson and Tu), St Michael's
Hospital (Dr Leiter), and the Division of General Internal Medicine, Sunnybrook
and Women's College Health Science Centre (Dr Tu), Toronto, Ontario. Dr Leiter
has received research funding from and has been a speaker for Merck Canada,
Montreal, Quebec, the manufacturer of simvastatin.
Corresponding author and reprints: Cynthia A. Jackevicius, BScPhm,
MSc, Pharmacy Department, University Health Network–Toronto General
Hospital, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4 (e-mail: cynthia.jackevicius{at}uhn.on.ca).
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