mmol/l 3 2.5 2 1.5 1 Secular trends in lipids after AMI Women Men 1994 1995 1996 1997 1998 1999 2000 2001 2002 Figure 3 Mean serum triglycerides in men and women at 3-months follow-up after hospitalization for ﬁrst myocardial infarction during 1994–2002. of initial cholesterol level. Following the results in the trial, patients are now routinely treated with 40 mg simvastatin, regardless of initial cholesterol concentrations. Among the 98 patients discharged in 2002, 8.1% (n = 8), however, had no lipid-lowering treatment due to side-effects (n = 2), liver disease (n = 4) or unknown reasons (n = 2). In the 4S trial 20 mg simvastatin daily lowered total serum cholesterol, on average, with 25% to 28% and LDL with 35% to 38% (1994). The HPS study (HPSCG 2002) showed a reduction in cardiovascular disease by 25% in individuals allocated to 40 mg simvastatin daily in comparison with the placebo group. Because one-sixth of the patients in the statin group in the HPS (HPSCG 2002) trial terminated their statin therapy, the potential reduction is probably underestimated. The average reduction in LDL cholesterol was 1.0 mmol/l, but this difference should probably also have been greater and has been estimated at 1.5 mmol/l (HPSCG 2002). Among the patients in the present study mean serum cholesterol decreased from about 6 mmol/l in both men and women to 4.31 and 5.13 mmol/l in men and women, respectively, cor- responding to what might have been expected in the men, but less than that in women. However, the decrease in total serum cholesterol may also partly be attributed to popula- tion trends, with decreasing total serum cholesterol in the Göteborg population (Wilhelmsen et al 1997; Berg et al 2005) and elsewhere (Evans et al 2001). This decrease is probably partly attributable to diet changes in the population (Becker and Pearson 2002), which include less saturated fat and more fruit and vegetables. Women with a ﬁrst AMI had higher mean levels of total serum cholesterol at the end of the study. This ﬁnding is explained by the fact that a higher proportion of women had less than the recommended dose Vascular Health and Risk Management 2007:3(6) of statin. In our study 20% (n = 20) of all patients had less than 40 mg simvastatin in the last year of the study; 18% of all men and 30% of all women. A decrease in mean serum triglycerides was also observed (from 2.55 and 2.16 mmol/l in 1994 to 1.72 and 1.77 mmol/l in 2002 in men and women, respectively). Although there is no target level for serum triglycerides in the current European guidelines (De Backer et al 2003), it is known to be an important risk factor, particularly in women (Sharrett et al 2001). In the deﬁnition from the US National Cholesterol Education program serum triglycerides 1.7 mmol/l are one of the criteria for the metabolic syndrome. Even though the target for lipid-lowering treatment is serum LDL cholesterol concentrations, triglyceride levels are also affected by statin treatment (Anonymous 1994). The increasing use of lipid-lowering drugs probably explains why serum triglycerides have decreased despite increasing BMI levels. In our population about two thirds of the men and women with a ﬁrst AMI were overweight. Despite widespread treatment with statins, a substantial proportion of the patients did not reach target levels for serum cholesterol. Target levels for total serum cholesterol ( 4.5 mmol/l) were met in 54% of the men and in 35% of the women. Of the 98 patients discharged after a ﬁrst AMI in 2002, 79 had simvastatin, 10 had atorvastatin, ﬂuvastatin, or pravastatin. Cholestipol hydrochloride was used in one patient. No patients took nicotinic acid or ﬁbrates. Eight patients had no lipid-lowering medication at all. Of those treated with simvastatin, 13 had 20 mg daily. Fiftyﬁve per cent of patients on the recommended dosage (40 mg daily) according to the HPS study (HPSCG 2002) (36/66 patients) reached the desired levels of 4.5 mmol/l for total serum cholesterol. 1049