Preprocedural statins reduce risk of postprocedure cardiovascular events

Using statins before invasive procedures significantly reduces the risk of postprocedural myocardial infarction, but not death, a new meta-analysis found.

Researchers chose randomized, controlled trials of patients who underwent an invasive procedure and had been randomized to statin therapy or control. Control meant placebo, usual care or low-dose statin therapy. Invasive procedures were defined as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or noncardiac surgical procedures, including vascular surgery. The researchers performed a literature search of the MEDLINE, Cochrane and clinicaltrials.gov databases from inception to February 2010 for studies in which statins were initiated before procedures and clinical outcomes were reported. Twenty-one trials with a total of 4,805 patients met their selection criteria. The results were reported in the Sept. 28 Journal of the American College of Cardiology.

The use of preprocedural statins significantly reduced postprocedural myocardial infarction (MI) compared with control (risk ratio [RR] 0.57; 95% CI, 0.46 to 0.70; P<0.0001). A 5.8% absolute risk reduction occurred after PCI (P<0.0001) and a 4.1% risk reduction after noncardiac surgical procedures (P=0.004), but there was no such reduction after CABG. The risk reduction for PCI occurred when statin therapy was initiated approximately one to seven days before the procedure, while statins started about four weeks before noncardiac surgical procedures reduced postoperative MI. There was no significant reduction in all-cause mortality with preprocedure statin use. Preprocedure statins also reduced post-CABG atrial fibrillation: Among the CABG studies, postoperative atrial fibrillation was 19% in the statin arm and 37% in the control arm (RR 0.54; 95% CI, 0.43 to 0.68; P<0.0001).

The authors concluded from the analysis that preprocedural statin therapy is beneficial, but noted that it's difficult to determine the type and dose of statins to use, or how long they should be used before a procedure. The PCI and surgical studies both used a wide variety of drugs and doses. Still, in the PCI studies, 56% of the weight of analysis came from trials with use of atorvastatin at 40 mg or more; 58% of the CABG studies' analysis entailed use of atorvastatin at 20 mg or more; and 91% of the analysis of noncardiac surgery trials entailed use of 80-mg doses of fluvastatin, they said. As for the finding that using statins preoperatively didn't reduce post-CABG MI, the authors noted the trials they found were small and involved low doses of statins, thus the issue deserves further study.