SHAPE Society

1. Statins are NOT good or fastStatins are NOT good or fast
enough; they areenough; they are
overrated!overrated!
Ward Casscells, MDWard Casscells, MD
University of Texas-Houston HSC &University of Texas-Houston HSC &
Texas heart instituteTexas heart institute

2. Vulnerable Plaques:Vulnerable Plaques:
Multifocal vs. SystemicMultifocal vs. Systemic

3. Vulnerable Plaque: A Multifocal DiseaseVulnerable Plaque: A Multifocal Disease
 Autopsy series:Autopsy series:
 A second occlusive thrombus in 6-16% of MI victimsA second occlusive thrombus in 6-16% of MI victims
 Angiography:Angiography:
 Second progressive lesion: 0-14%Second progressive lesion: 0-14%
 Second vulnerable lesions 2.6 per U/A patientSecond vulnerable lesions 2.6 per U/A patient
 IVUS:IVUS:
 2 or more plaque ruptures in 50-79% of ACS patients2 or more plaque ruptures in 50-79% of ACS patients

4. Vulnerable Plaque: A Multifocal DiseaseVulnerable Plaque: A Multifocal Disease
 Angioscopy:Angioscopy:
 Almost always reveals only one thrombus in MIAlmost always reveals only one thrombus in MI
patientspatients
 Yellow plaques in some patients with stable anginaYellow plaques in some patients with stable angina
 Yellow plaques in most patients with unstable anginaYellow plaques in most patients with unstable angina
 Yellow plaques in nearly all patients with AMIYellow plaques in nearly all patients with AMI
 Thermal heterogeneity found in:Thermal heterogeneity found in:
 Some patients with stable anginaSome patients with stable angina
 In almost all patients with unstable anginaIn almost all patients with unstable angina
 Two or even three hot plaques in AMITwo or even three hot plaques in AMI

5. What to do with vulnerable plaquesWhat to do with vulnerable plaques
once we find them?once we find them?

6. Do statins work fast enough?Do statins work fast enough?
None of the 6 large clinical trails showedNone of the 6 large clinical trails showed
any significant decrease in mortality in theany significant decrease in mortality in the
first year of statin therapyfirst year of statin therapy

7. 4S
WOSCOPS
CARE
AFCAPS/TexCAPS
HPS

8. Do statins protect enough?Do statins protect enough?
On average, 42% of deaths in statin trialsOn average, 42% of deaths in statin trials
happened in their statin arms.happened in their statin arms.

9. Coronary Death in the Statin ArmCoronary Death in the Statin Arm
of Clinical Trialsof Clinical Trials
TrialTrial % Coronary Death% Coronary Death
4S4S 3737
LIPIDLIPID 4343
WOSCOPSWOSCOPS 4242
CARECARE 4444
MRC/BHFMRC/BHF 4545
AFCAPS/TEXCAPSAFCAPS/TEXCAPS 4242
PROSPERPROSPER 4343

10. Why protection is delayed?Why protection is delayed?
Lipid-lowering and anti-inflammatoryLipid-lowering and anti-inflammatory
effects of statins begin by 6 weeks.effects of statins begin by 6 weeks.
However, death rate is delayed for at leastHowever, death rate is delayed for at least
12 months.12 months.
Is there a hidden increase in risk whichIs there a hidden increase in risk which
counters the benefits in the first year?counters the benefits in the first year?
Q: How the macrophages exit the plaque?Q: How the macrophages exit the plaque?
Do they weaken the fibrous cap on exit?Do they weaken the fibrous cap on exit?

11. What should be done?What should be done?
Use multiple therapies:Use multiple therapies:
Various combinations ofVarious combinations of
 Aspirin with warfarin or clopidogrelAspirin with warfarin or clopidogrel
 ACE inhibitors with beta-adrenergic blockersACE inhibitors with beta-adrenergic blockers
 statins with niacin, fibrates, and resinsstatins with niacin, fibrates, and resins
 Mediterranean dietMediterranean diet
 Fight triggersFight triggers
 Flu shotFlu shot
 Etc.Etc.

12. Local therapy to buy timeLocal therapy to buy time
Since statins may not reduce mortality inSince statins may not reduce mortality in
time, the most vulnerable plaques maytime, the most vulnerable plaques may
merit stenting or some other form of localmerit stenting or some other form of local
therapy to “buy time”.therapy to “buy time”.