Can Preventive Therapy Alter the Initial Presentation of Coronary Heart Disease?

During the past 2 decades, a large body of evidence has accumulated about the effects of medical therapies given to reduce the risk for events associated with coronary heart disease (CHD). These studies and trials have usually focused on hard end points, such as total mortality rate, fatal and nonfatal myocardial infarction, and sudden death. Together, these interventions reduce the risk for a CHD event, especially when used in patients with known CHD (secondary prevention) and in high-risk patients with no history of CHD (primary prevention). In contrast, we know little about how these primary preventive therapies affect the way in which CHD initially presents (as the acute coronary syndrome or as stable angina pectoris).

The article by Go and colleagues in this issue (1) attempts to determine whether the recent use of medication (statins, β-blockers, and angiotensin-converting enzyme [ACE] inhibitors) or patient characteristics influence the manner of initial clinical presentation of CHD. The authors used observational data from patients who were enrolled in Kaiser Permanente of Northern California. All patients had no history of CHD. The authors divided the study sample into 2 groups: those who presented with myocardial infarction (men between 45 and 75 years of age and women between 55 and 75 years of age) and those who presented with stable exertional angina pectoris (men and women between 18 and 75 years of age). The authors compared the characteristics of these 2 groups. Patients who presented with acute myocardial infarction as the first manifestation of CHD were more likely to …