Postoperative Myocardial Injury and Inflammation Is Not Blunted by a Trial of Atorvastatin in Orthopedic Surgery Patients

Statin use in total joint arthroplasty: a systematic review

Introduction

There has been increased interest in the use of Statins in total hip and knee arthroplasty (THA and TKA) patients to improve outcomes and reduce postoperative complications. This study was performed to systematically review the evidence on Statin use in total joint arthroplasty, specifically its benefits and complications.

Methods

Adhering to the PRISMA guidelines, a systematic review of PubMed, Embase, Scopus, Web of Science, and the Cochrane database was performed to find studies reporting on the effects of Statin use on outcomes of THA and TKA. Two authors independently selected relevant papers to include.

Results

A total of 18 papers were included in the final analysis. Most were retrospective studies, with heterogeneous patient selection and outcome measures. The evidence on the risks and benefits of Statin use on outcomes of total joint arthroplasty was very limited and heterogeneous. Studies were focusing on perioperative cardiac outcomes, clinical outcomes and complications, renal, pulmonary, and gastrointestinal outcomes. Due to the heterogeneity of reported data, a formal meta-analysis was not possible.

Conclusions

There is some evidence in the literature suggesting that perioperative use of Statins, especially in Statin-naïve patients, may reduce cardiac (e.g. atrial fibrillation) and noncardiac (e.g. delirium) complications, while not increasing the risk of muscle or liver toxicity. The authors also found low levels of evidence that Statin use may reduce the long-term risk for revision surgery and osteolysis.

Ivabradine in the Prevention, and Reduction in Size, of Perioperative Myocardial Injury in Patients Undergoing Orthopedic Surgery for Acute Fracture

BACKGROUND

Perioperative myocardial injury is common after major noncardiac surgery and is associated with adverse outcomes. This study investigated the use of ivabradine in patients undergoing urgent surgery for fracture.

METHODS AND RESULTS

This was a prospective, double-blind, placebo-controlled, randomized clinical trial. Participants were enrolled 1:1 into ivabradine or placebo arm, and study drug was commenced before operation and continued for 7 days or until discharge. High-sensitivity troponin I was measured daily using Abbott Alinity analyzer and assay, and heart rate data were obtained using continuous Holter monitoring. A total of 199 patients underwent acute orthopedic surgery, 98 in the ivabradine group and 101 in the placebo group. The mean age was 78.7 years (range, 77.5-79.9 years), with 68% women. The average heart rate was 5 to 11 beats per minute lower in the ivabradine group compared with the placebo group at all time points (P<0.001 for all). There was no statistically significant difference between the ivabradine and placebo groups in the number of patients who had perioperative myocardial injury: 28.6% versus 31.6% (P=0.71). In patients with perioperative myocardial injury, average peak troponin was 168.8 ng/L (±431.2 ng/L) in the ivabradine group and 2094.5 ng/L (±7201.9 ng/L) in the placebo group (P=0.16). There was no statistically significant difference between groups in 30-day mortality, blood pressure, stroke, or major adverse cardiovascular event.

CONCLUSIONS

Starting ivabradine preoperatively in elderly patients requiring acute surgery for fracture did not result in a statistically significant difference in the incidence of perioperative myocardial injury. There was no statistically significant difference in morbidity, mortality, or adverse events between treatment groups.

REGISTRATION

URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616001634460p.

Preadmission Statin Prescription and Inpatient Myocardial Infarction in Geriatric Hip Fracture

Statins have been shown to reduce myocardial infarction (MI) in cardiac and vascular surgery. MI is common in hip fracture. This study aims to investigate whether statins decrease MI in hip fracture surgery and reduce mortality resulting from MI. Patients aged 65 years and above with a low-energy hip fracture were identified between January 2015 and December 2017. Demographics, comorbidities, predictive scores, medications and outcomes were assessed retrospectively. The primary outcome was inpatient MI. The secondary outcome was inpatient mortality resulting from MI, for which fatal and non-fatal MI were modelled. Regression analysis was conducted with propensity score weighting. Hip fracture occurred in 1166 patients, of which 391 (34%) were actively taking statins. Thirty-one (2.7%) patients were clinically diagnosed with MI. They had a higher inpatient mortality than those who did not sustain an MI (35% vs. 5.3%, p < 0.0001). No reduction was seen between statin use and the occurrence of MI (OR = 0.97, 95% CI: 0.45-2.11; p = 0.942) including Fluvastatin-equivalent dosage (OR = 1.00, 95% CI: 0.96-1.03, p = 0.207). Statins were not associated with having a non-fatal MI (OR 1.47, 95% CI: 0.58-3.71; p = 0.416) or preventing fatal MI (OR = 0.40, 95% CI: 0.08-1.93; p = 0.255). Preadmission statin use and associations with clinically diagnosed inpatient MI or survival after inpatient MI were not able to be established.

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Background

The effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome.

Methods

Electronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility.

Results

We included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30–0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70–1.24], p = 0.61) (p_subgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00–1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71–3.26], p = 0.28) (p_subgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03–13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic.

Conclusions

Perioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0441-3) contains supplementary material, which is available to authorized users.

Effects of perioperative statins on patient outcomes after noncardiac surgery: a meta-analysis

BACKGROUND

Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. However, controversy remains regarding whether perioperative administration of hydroxymethylglutaryl-CoA reductase inhibitors (statins) has a beneficial effect on patient outcomes.

OBJECTIVE

We performed a meta-analysis to validate the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery.

METHODS

Electronic databases (PubMed, Web of Science, EMBASE, and the Cochrane Library) were searched for randomized controlled trials (RCTs) published up to 10 November 2017. RCTs were eligible for inclusion if they compared perioperative statin treatment with control treatment in patients scheduled for noncardiac surgery and reported data pertaining to clinical outcomes.

RESULTS

Twelve RCTs involving 4707 patients (2371 in the perioperative statin group and 2336 in the control group) were ultimately included in this meta-analysis. The incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation were all lower in patients treated with statins than in control group patients, as shown by the fixed-effects model (odds ratio (OR) = 0.460, 95% confidence interval (CI) = 0.324-0.653, p = 0 for myocardial infarction; OR = 0.617, 95% CI = 0.476-0.801, p = 0 for composite of death/myocardial infarction/stroke; OR = 0.406, 95% CI = 0.247-0.666, p = 0 for new atrial fibrillation). No significant differences in the incidences of stroke or transient ischemic attack, all-cause mortality and cardiovascular mortality were observed between the statin and control arms.

CONCLUSIONS

This meta-analysis supports the hypothesis that perioperative statins effectively reduce the incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation in patients undergoing noncardiac surgery. Key Messages Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. We performed a meta-analysis to confirm the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery.