(Circulation. 1997;96:4211-4218.)
© 1997 American Heart Association, Inc.
Articles |
Cholesterol-Lowering Therapy in Women and Elderly Patients With Myocardial Infarction or Angina Pectoris
Findings From the Scandinavian Simvastatin Survival Study (4S)
From the Department of Medicine, University of Helsinki (Finland) (T.A.M.); Department of Medicine, University of Kuopio (Finland) (K.P.); Department of Internal Medicine, Linköping (Sweden) University Hospital (A.G.O.); Merck Research Laboratories, Rahway, NJ (T.A.M., T.J.C.); Århus (Denmark) University Hospital (O.F.); Institute of Medical Genetics, University of Oslo (Norway) (K.B.); Medical Department, Åker Hospital, Oslo, Norway (T.P.); and Department of Medicine, Rikshospitalet, Oslo, Norway (J.K.).
Correspondence to Prof Tatu Miettinen, Department of Medicine, University of Helsinki, 00290 Helsinki 29, Finland.
Background The Scandinavian Simvastatin
Survival Study (4S) demonstrated pronounced reductions in mortality and
major coronary events in a cohort of patients with established
coronary heart disease (CHD). The present study provides a
detailed, post hoc assessment of the efficacy and safety of
simvastatin therapy in the following subgroups of 4S
patients: those 
65 years of age, those <65 years of age, women,
and men.
Methods and Results The 4S cohort of 4444 CHD patients included
827 women and 1021 patients 65 years of age. Total
cholesterol at baseline was 5.5 to 8.0 mmol/L with
triglycerides 
2.5 mmol/L. Patients were randomized
to therapy with simvastatin 20 to 40 mg daily or placebo
for a median follow-up period of 5.4 years. End points consisted of
all-cause and CHD mortality, major coronary events (primarily
CHD death and nonfatal myocardial infarction), other acute CHD and
atherosclerotic events, hospitalizations for CHD and
cardiovascular events, and coronary
revascularization procedures. Mean changes in serum
lipids were similar in the different subgroups. In patients 65 years
of age in the simvastatin group, relative risks (95%
confidence intervals) for clinical events were as follows: all-cause
mortality, 0.66 (0.48 to 0.90); CHD mortality, 0.57 (0.39 to 0.83);
major coronary events, 0.66 (0.52 to 0.84); any
atherosclerosis-related event, 0.67 (0.56 to 0.81); and
revascularization procedures, 0.59 (0.41 to 0.84).
In women, the corresponding figures were 1.16 (0.68 to 1.99); 0.86
(0.42 to 1.74), 0.66 (0.48 to 0.91), 0.71 (0.56 to 0.91), and 0.51
(0.30 to 0.86), respectively.
Conclusions Cholesterol lowering with
simvastatin produced similar reductions in relative risk
for major coronary events in women compared with men and in
elderly (65 years of age) compared with younger patients. There were
too few female deaths to assess the effects on mortality in women.
Because mortality rates increased substantially with age, the absolute
risk reduction for both all-cause and CHD mortality in
simvastatin-treated subjects was approximately twice as
great in the older patients.
Key Words: hypercholesterolemia • coronary disease • simvastatin • mortality
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