REDUCING THE RISK OF CORONARY EVENTS - EVIDENCE FROM THE SCANDINAVIAN SIMVASTATIN SURVIVAL STUDY (4S)

The Scandinavian Simvastatin Survival Study (4S) was designed to evaluate the effects of cholesterol reduction with simvastatin on mortality and morbidity in patients with coronary artery disease (CAD). A total of 4,444 patients with angina pectoris or previous myocardial infarction and serum cholesterol levels of 213-310 mg/dl (5.5-8.0 mmol/liter) while treated with a lipid-lowering diet were randomly assigned to double-blind treatment with simvastatin or placebo. Over the 5.4 years of median follow-vp, simvastatin produced changes in total cholesterol, low density lipoprotein (LDL) cholesterol, and high density lipoprotein (HDL) cholesterol of -25%, -35%, and +8%, respectively, with minimal adverse effects. A total of 256 patients (12%) in the placebo group died compared with 182 (8%) in the simvastatin group, a risk reduction of 30% (p = 0.0003) attributable to a 42% reduction in the risk of coronary death. Noncardiovascular causes accounted for 49 and 46 deaths in the placebo and simvastatin groups, respectively. Major coronary events were experienced by 622 patients (28%) in the placebo group and 431 patients (19%) in the simvastatin group, corresponding to a risk reduction of 34% (p < 0.00001). This risk was also significantly reduced in subgroups consisting of women and patients of both sexes aged greater than or equal to 60 years. Other benefits of treatment included a 37% reduction (p < 0.00001) in the risk of undergoing myocardial revascularization procedures. Simvastatin was beneficial regardless of whether patients had a history of myocardial infarction or whether they were smokers or had hypertension. Although only 202 patients had diabetes at randomization, 4 significant reduction in major coronary events was noted in this group (p = 0.002). The beneficial effect of simvastatin was also found to be independent of concomitant therapy with aspirin, beta blockers, or calcium antagonists and was consistent across the whole range of baseline LDL cholesterol levels. This study shows that long-term treatment with simvastatin is safe and improves survival in CAD patients.