Preoperative statin use and outcomes following cardiac surgery

Does high dose statin pretreatment affect global strains in patients undergoing valve replacement

Purpose

To study the effect of rosuvastatin 40 mg (initiated 7 days prior to surgery) in patients undergoing valve replacement (VR) for rheumatic mitral valve disease on left ventricular (LV) strain and biomarker release kinetics.

Methods

In this randomized study, cardiac biomarkers viz. troponin I (TnI), Creatine kinase MB (CK-MB), N-terminal pro B-type natriuretic peptide (NTPBNP) were measured before surgery; and 8, 24 and 48 h postoperatively. Global LV (circumferential, global circumferential strain (GCS); longitudinal, GLS; radial, global radial strain (GRS)) strains were measured preoperatively; and 48 h and 30 days postoperatively.

Results

Following VR, Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS) and Global Radial Strain (GRS) declined at 48 h in both statin loaded (SL) and non loaded (NL) groups. The %decline in strain was significantly lower in SL group (% change in GLS 35.8% vs 38.8%, GCS 34% vs 44.1%, GRS 45.7% vs 52.6%; p < 0.001).All strain values improved at 30 days with higher improvement in SL group (GLS -15.92 ± 2.00% vs -12.6 ± 1.66%, GCS -15.12 ± 2.93% vs -13.04 ± 2.44%; GRS 22.12 ± 6.85% vs 19.32 ± 6.48%). While TnI, CKMB, NTPBNP increased following surgery, values at 8, 24 and 48 h were lower in the SL vs. NL group. Mean change (baseline to peak biomarker value) was also significantly lower in SL group.The SL group had shorter hospital and Intensive Care Unit (ICU) stay. On Receiver Operating Characteristic Curve (ROC) analysis, baseline GCS ≤ 14% best predicted postoperative 30 day Left Ventricular Ejection Fraction (LVEF) ≤ 50%.

Conclusion

Pre-operative high dose rosuvastatin was "cardioprotective" with favorable effect on LV global strain and release kinetics of biomarkers. These cut-offs (described for the first time for rheumatic VR) can be used as prognostic predictors.

Statin reload before off-pump coronary artery bypass graft: Effect on biomarker release kinetics

Objectives

Statins confer protection from ischemia/reperfusion through various pathways including pleiotropic mechanisms. Following chronic administration, activation of intrinsic cellular mechanisms causes attenuation of these pleiotropic effects.

Methods

Since coronary artery bypass surgery (CABG) represents a reversible ischemia-reperfusion sequence, we assessed if statin reload is effective in patients undergoing off-pump CABG (n = 100) in limiting myocardial injury. Patients received loading dose of rosuvastatin (40 mg initiated 7 days before surgery) while nonloaded patients continued whatever statin dose they were receiving and served as controls. Cardiac biomarkers (Troponin-I, creatine kinase muscle/brain [CK-MB], and B-type natriuretic peptide [BNP]) were measured at 8, 24, and 48 h postoperatively. The primary end-point was the extent of perioperative myocardial injury (area under the curve [AUC]: AUC of each biomarker).

Results

Despite similar baseline levels, all biomarkers at 8, 24, and 48 h were significantly lower in the loaded group. The AUC for each biomarker was also significantly lower in the loaded group (cTnI 37.96 vs. 70.12 ng. hr/ml, CK-MB 229.64 vs. 347.04 ng. hr/ml, and BNP 5257.56 vs. 15606.68 pg. hr/ml, all P < 0.001). Delta cTnI (change from baseline to peak level) (1.00 ± 1.34 vs. 2.25 ± 2.59), delta CK-MB (4.54 ± 5.89 vs. 10.68 ± 9.95), and delta BNP (120.41 ± 172.48 vs. 449.23 ± 790.95) all P < 0.001 were also significantly lower in the loaded group. Those loaded with rosuvastatin had lower inotrope duration (22.9 ± 23.33 vs. 31.26 ± 25.39 h, P = 0.04) and ventilator support time (16.94 ± 6.78 vs. 23.8 ± 20.53 h, P = 0.03).

Conclusion

In patients undergoing off-pump CABG, statin reload can "recapture" cardioprotection in patients already on statins with favorable effect on release kinetics of biomarkers and postoperative outcomes.

The Impact of Statins before High-Risk CABG on Postoperative Multiple Organ Function

Background

The purpose of this cohort study was to investigate the independent relationship between preoperative statin therapy (PST) and postoperative severe multiorgan failure, measured by the Sequential Organ Failure Assessment (SOFA) maximum greater than 11, in high-risk patients undergoing isolated coronary artery bypass grafting (CABG).

Methods

The present study is a perspective, single-center, cohort analysis enrolling high-risk patients undergoing CABG from Jan 1, 2018, to Dec 31, 2018, in Beijing Anzhen hospital.

Results

Among a total of 880 high-risk patients undergoing isolated CABG included in this study, 503 (57.2%) experienced statin therapy before CABG. The SOFA maximum was significantly lower in the PST group compared with the control group (7.8 ± 3.0 v 9.2 ± 3.4, P < 0.0001). Multivariate logistic regression analysis demonstrated the incidence of the severe multiorgan dysfunction, measured by SOFA maximum ≥11, was dramatically reduced in the PST group (OR, 0.68, 95% CI 0.50-0.92, P=0.013). Furthermore, preoperative statin therapy (PST) might be associated with a decreased risk of postoperative major adverse cardiovascular and cerebral events and acute kidney injury, but an increased risk of postoperative hepatic inadequacy.

Conclusion

SOFA maximum was significantly lower in the PST group compared with the control group and the incidence of the severe multiorgan dysfunction was dramatically reduced in the PST group. The findings of this study might shed new light on questions of positive or negative effects of PST on multiple organ function after high-risk CABG, so as to ultimately improve high-risk patient in-hospital outcomes from CABG.

Lack of Association between Preoperative Statin Use and Respiratory and Neurologic Complications after Cardiac Surgery

Background

Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery.

Methods

The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models.

Results

Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay.

Conclusions

Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.

Statins and the Perioperative Period

Recent studies on the effects of statin use on perioperative morbidity and mortality suggest that statins may reduce risk during the perioperative period. However, studies published thus far either were retrospective nonrandomized studies or included small numbers of patients. Individually, none offered authoritative recommendations. However, in almost every study, preoperative statin use was associated with a substantial improvement in perioperative outcome. Thus, pending the publication of a large, prospective randomized trial, the preponderance of the evidence at this time suggests that perioperative statin usage may improve outcome in high-risk patients undergoing major surgery. Furthermore, even if statins are definitively found to be effective, additional studies will be necessary to establish the optimal timing of initiation, drug dosages, and length of therapy.

Association between Preoperative Statin Therapy and Postoperative Infectious Complications in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

Infectious complications of cardiac surgery are often severe and life threatening. Statins having both immunomodulatory and anti-inflammatory effects were intuitively thought to influence the development of postsurgical infections. We sought to systematically examine whether any association exists between statin use and risk of infectious complications in patients undergoing cardiac surgery. We searched Ovid MEDLINE, Ovid EMBASE, Thomson Scientific Web of Science, and Elsevier Scopus from inception through February 2011 for comparative studies examining the association between statin use and risk of postoperative infections in patients undergoing cardiac surgery. We contacted a study's author for missing information. We conducted a random-effects meta-analysis of individual studies' odds ratios (adjusted for potential confounders). We identified 6 cohort studies for inclusion, 3 of which were conducted in Canada and 3 of which were conducted in the United States. Four were single-center studies, and 2 were population based. Exposure ascertainment was based on a review of admission medication list or prescription databases. Infectious outcomes were heterogeneous and included surgical site infections within 30 days, serious infections (sepsis), or any other postoperative infection. Statin use in the preoperative period was associated with a trend toward reduction in the incidence of postoperative infections in patients who underwent cardiac surgery (odds ratio, 0.81 [95% confidence interval, 0.64–1.01]; P = .06; I2 = 75%). Heterogeneity was explained by country effect. Studies performed in Canada showed weaker associations than studies performed in the United States. This difference could not be attributed to study quality alone. We did not find good evidence to support an association between statin use and postoperative infectious complications. However, the trend toward statistical significance for this association indicates that further investigation is warranted.

Preoperative statin therapy is associated with lower requirement of renal replacement therapy in patients undergoing cardiac surgery: a meta-analysis of observational studies

OBJECTIVES

Acute kidney injury (AKI) following cardiac surgery is a common complication associated with serious morbidity and mortality. Activation of inflammatory cascade and vascular endothelial dysfunction plays a vital role during the perioperative period leading to AKI. Statins are known to suppress inflammation and improve endothelial dysfunction over and above the cholesterol lowering efficacy.

METHODS

Observational studies with a defined population in terms of preoperative statin therapy and no preoperative statin therapy undergoing cardiac surgery (CABG, isolated valve surgery or both) and with reported data on the incidence of acute renal failure/injury and/or mortality were identified and analysed for inclusion in the analysis. Outcomes evaluated were occurrence of postoperative acute kidney injury/failure, requirement of any postoperative renal replacement therapy and short-term all-cause mortality rate. A meta-analysis was conducted and a pooled estimate of odds ratio (OR) was calculated using the inverse variance method.

RESULTS

A total of 17 studies with a total population of 24 998 statin users and 22 082 non-statin users were included in the final analysis. PST resulted in a significantly lower incidence of renal replacement therapy in patients undergoing CABG (OR: 0.56 [0.41-0.76]) but not in isolated valve surgery (OR: 1.80 [0.73-4.44]). Also preoperative statin therapy resulted in a significantly lower postoperative mortality (0.72 [0.61-0.84]) irrespective of the type of surgery. There was no effect of preoperative statin therapy on the incidence of AKI in any of the sub-group of the patients.

CONCLUSIONS

Patients undergoing CABG might derive benefit from preoperative statin therapy in terms of reducing the need for postoperative renal replacement therapy and mortality. However, the uncertainty concerning the reno-protective efficacy of preoperative statin therapy in patients undergoing isolated valve surgery needs further investigation.

Preoperative statin therapy in cardiac surgery: a meta-analysis of 90,000 patients

The objective of this systematic literature review with meta-analysis was to determine the strength of evidence for a preoperative statin on the reduction of adverse postoperative outcomes in patients undergoing cardiac surgery. Randomized controlled (RCT) and observational trials were searched in online databases that reported about the effects of preoperative statin therapy on major adverse clinical outcomes after cardiac surgery. Analysed outcomes included early all-cause mortality, myocardial infarction, atrial fibrillation (AF), stroke and renal failure using a priori-defined criteria. Effect estimates were calculated and are given as odds ratio (OR) with 95% confidence intervals (95% CI) using fixed- or random-effect models. Literature search of all major databases retrieved 2371 studies. After screening, a total of 54 trials were identified (12 RCT, 42 observational) that reported outcomes of 91 491 cardiac surgery patients with (n = 46 614; 51%) or without (n = 44 877; 49%) preoperative statin therapy. Preoperative statin use resulted in a 0.9% absolute risk (2.6 vs 3.5%) and a 31% odds reduction for early all-cause mortality (OR 0.69; 95% CI 0.59-0.81; P < 0.0001). In addition, statin treatment before surgery was associated with a substantial reduction (P < 0.01) in the postoperative end-points AF (OR 0.71; 95% CI 0.61-0.82), new-onset AF (OR 0.68; 95% CI 0.54-0.85), stroke (OR 0.83; 95% CI 0.74-0.93), stay on intensive care unit (weighted mean difference [WMD] -0.14; 95% CI -0.23 to -0.03; P < 0.01) and in-hospital stay (WMD -0.57; 95% CI -0.76 to -0.38; P < 0.01). No statistical differences were found between groups with regard to myocardial infarction or renal failure. In conclusion, the current systematic review strengthens the evidence that preoperative statin therapy extends substantial clinical benefit to early postoperative outcomes in cardiac surgery patients.

Simvastatin reduces myocardial injury undergoing noncoronary artery cardiac surgery: a randomized controlled trial

OBJECTIVE

Myocardial injury during cardiac surgery is a major cause of perioperative morbidity and mortality. We determined whether perioperative statin therapy is cardioprotective in patients undergoing noncoronary artery cardiac surgery and the potential mechanisms.

METHODS AND RESULTS

One hundred fifty-one patients undergoing noncoronary artery cardiac surgery were randomly assigned to either a statin group (n=77) or a control group (n=74). Simvastatin (20 mg) was administered preoperatively and postoperatively. Plasma were analyzed for troponin T, isoenzyme of creatine kinase, C-reaction protein, interleukin-6, interleukin-8, creatinine, and blood urea nitrogen. Cardiac echocardiography was performed. Endothelial nitric oxide synthase (eNOS), Akt, p38, heat shock protein 90, caveolin-1, and nitric oxide (NO) in the heart were detected. Simvastatin significantly reduced plasma troponin T, isoenzyme of creatine kinase, C-reaction protein, blood urea nitrogen , creatinine, interleukin-6, interleukin-8, and the requirement of inotropic postoperatively. Simvastatin increased NO production, the expression of eNOS and phosphorylation at serine1177, phosphorylation of Akt, expression of heat shock protein 90, heat shock protein 90 association with eNOS and decreased eNOS phosphorylation at threonine 495, phosphorylation of p38, and expression of caveolin-1. Simvastatin also improved cardiac function postoperatively.

CONCLUSIONS

Perioperative statin therapy can improve cardiac function and renal function by reducing myocardial injury and inflammatory response through activating Akt-eNOS and attenuating p38 signaling pathways in patients undergoing noncoronary artery cardiac surgery. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01178710.

Pilot double-blind, randomized controlled trial of short-term atorvastatin for prevention of acute kidney injury after cardiac surgery

AIM

To test whether short-term perioperative administration of oral atorvastatin could reduce incidence of postoperative acute kidney injury (AKI) in cardiac surgical patients.

METHODS

We conducted a double-blind, randomized controlled trial in 100 cardiac surgical patients at increased risk of postoperative AKI. Patients were randomized to atorvastatin (40 mg once daily for 4 days starting preoperatively) or identical placebo capsule. Primary outcome was to detect a smaller absolute rise in postoperative creatinine with statin therapy. Secondary outcomes included AKI defined by the creatinine criteria of RIFLE consensus classification (RIFLE R, I or F), change in urinary neutrophil gelatinase-associated lipocalin (NGAL) concentration, requirement for renal replacement therapy, length of stay in intensive care, length of stay in hospital and hospital mortality.

RESULTS

Study groups were well matched. For each patient maximal increase in creatinine during the 5 days after surgery was assessed; median maximal increase was 28 µmol/L in the atorvastatin group and 29.5 µmol/L in the placebo group (P = 0.62). RIFLE R or greater occurred in 26% of patients with atorvastatin and 32% with placebo (P = 0.65). Postoperatively urine NGAL changes were similar (median NGAL : creatinine ratio at intensive care unit admission: atorvastatin group 1503 ng/mg, placebo group 1101 ng/mg; P = 0.22). Treatment was well tolerated and adverse events were similar between groups.

CONCLUSION

Short-term perioperative atorvastatin use was not associated with a reduced incidence of postoperative AKI or smaller increases in urinary NGAL. (ClinicalTrials.gov NCT00910221).

Statins reduce short- and long-term mortality associated with postoperative atrial fibrillation after coronary artery bypass grafting: impact of postoperative atrial fibrillation and statin therapy on survival

BACKGROUND

Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass grafting (CABG) surgery. The objective of this study was to determine the impact of POAF on both short- and long-term mortality following isolated CABG.

HYPOTHESIS

POAF is associated with a poorer short and long-term mortality following CABG.

METHODS

We retrospectively analyzed the preoperative and operative data of 6728 consecutive patients undergoing a first isolated CABG.

RESULTS

The incidence of POAF was 27.8%. Operative mortality was higher in patients with POAF compared to those without POAF (2.3% vs 0.9%, P < 0.001). On multivariate analysis, POAF remained an independent predictor of operative mortality (odds ratio [OR]: 1.78, P = 0.01). Patients with POAF also had reduced long-term survival (6-year survival: 85.3% vs 89.2%, P < 0.001). After adjusting for other predictors of mortality, POAF was significantly associated with increased long-term mortality (hazard ratio [HR]: 1.35, P = 0.04). Of note, after adjustment for potential confounders, statin treatment had a highly protective effect in POAF patients for both operative mortality (OR: 0.38, P = 0.003) and long-term mortality (HR: 0.62, P = 0.03), whereas it had no significant effect in patients without POAF.

CONCLUSIONS

POAF is an independent predictor of both short- and long-term mortality following CABG. Moreover, statin therapy was independently associated with better survival in patients with POAF.

Current evidence for perioperative statins in cardiac surgery

Cardiac surgery improves life expectancy and quality of life for the constantly ageing population in developed countries. Mediated by their lipid-dependent and lipid-independent mechanisms, statins are sought to provide benefit with regard to better outcomes after cardiac surgery. Current guidelines recommend statin use in patients undergoing coronary artery bypass grafting, while less evidence is available for patients referred to heart valve surgery. Optimal selection of statin drug and dosage including perioperative timing of statin therapy remains largely unknown, but results of ongoing meta-analyses and future randomized trials will add important evidence to guide perioperative statin treatment of cardiac surgery patients.

Perioperative statin use: an update

HMG CoA reductase inhibitors (statins) are a proven modality to reduce serum cholesterol and have been shown to reduce morbidity and mortality in cardiovascular patients. Statins have also demonstrated improvements in postoperative outcomes among patients taking them in the perioperative period. Many of the studies are limited to select patient populations and/or select surgeries. This review will give an overview of the pharmacology of statins, summarize the mechanisms of the beneficial effects of statins, and provide an overview of evidence in the use of statins in the perioperative period.

[Effect of the administration of statins in non-cardiac critical disease]

Administration of statins has been shown to be effective in reducing cardiovascular mortality. Their benefit could expand towards other areas of intensive medicine, it being possible to decrease mortality of the critically ill patient. There are several studies, although without a high level of evidence, that have detected a possible benefit when they are administered as well as clinical deterioration when they are discontinued, compared to those patients who had previously taken them. Even though most of the patients who had previously taken statins did so as primary or secondary prevention, thus having greater comorbidity, overall, a decrease is detected in the mortality of these subgroups. This benefit could be generalized to all the critical conditions, although studies with a higher level of evidence are needed for their adequate comparison.

Primer on statistical interpretation or methods report card on propensity-score matching in the cardiology literature from 2004 to 2006: a systematic review

BACKGROUND

Propensity-score matching is frequently used in the cardiology literature. Recent systematic reviews have found that this method is, in general, poorly implemented in the medical literature. The study objective was to examine the quality of the implementation of propensity-score matching in the general cardiology literature.

METHODS AND RESULTS

A total of 44 articles published in the American Heart Journal, the American Journal of Cardiology, Circulation, the European Heart Journal, Heart, the International Journal of Cardiology, and the Journal of the American College of Cardiology between January 1, 2004, and December 31, 2006, were examined. Twenty of the 44 studies did not provide adequate information on how the propensity-score-matched pairs were formed. Fourteen studies did not report whether matching on the propensity score balanced baseline characteristics between treated and untreated subjects in the matched sample. Only 4 studies explicitly used statistical methods appropriate for matched studies to compare baseline characteristics between treated and untreated subjects. Only 11 (25%) of the 44 studies explicitly used statistical methods appropriate for the analysis of matched data when estimating the effect of treatment on the outcomes. Only 2 studies described the matching method used, assessed balance in baseline covariates by appropriate methods, and used appropriate statistical methods to estimate the treatment effect and its significance.

CONCLUSIONS

Application of propensity-score matching was poor in the cardiology literature. Suggestions for improving the reporting and analysis of studies that use propensity-score matching are provided.

Preoperative statin therapy is not associated with a reduced incidence of postoperative acute kidney injury after cardiac surgery

BACKGROUND

Our objective was to examine the association between preoperative statin therapy and the prevalence of postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery with the use of cardiopulmonary bypass.

METHODS

We performed a retrospective investigation of 10,648 consecutive patients undergoing coronary artery bypass grafting using cardiopulmonary bypass and/or valve surgery between January 2002 and December 2006. Patients were divided into 2 groups depending on preoperative therapy with statin drugs. The primary outcome was postoperative AKI based on the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria. Secondary outcomes included requirement for postoperative dialysis and hospital mortality. Multivariable logistic regression models were developed for the primary and secondary outcomes. To control for selection bias related to statin therapy, a propensity score was developed using a greedy matching technique.

RESULTS

The incidence of AKI was 12.1% (n = 1286). AKI occurred in 13.31% of patients receiving preoperative statins (819 of 6152 patients) versus 10.41% in the no statin group (467 of 4487 patients) (P < 0.001). The incidence of postoperative dialysis was 1.71% (n = 182). Postoperative dialysis was needed in 1.75% of patients in the statin group (108 of 6157 patients) compared with 1.65% of patients (74 of 4491 patients) in the no statin group (P = 0.68). Hospital mortality after surgery occurred in 1.71% (n = 182) of patients. The incidence of mortality for patients in the statin group was 1.71% (105 of 6157 patients) and this was not different from mortality in the no statin group of 1.71% (77 of 4491 patients) (P = 0.97). In multivariate logistic regression analysis, statin therapy was not associated with AKI (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.84-1.12; P = 0.68), postoperative dialysis (OR 0.80, 95% CI 0.55-118; P = 0.23), or hospital mortality (OR 0.803, 95% CI 0.56-1.16; P = 0.24). In 2646 propensity-matched pairs, the incidence of AKI was 12.0% in the statin group versus 12.8% in the no statin group (P = 0.38). The statin group had a 1.63% incidence of postoperative dialysis versus 2.08% in the no statin group (P = 0.22). In the same propensity-matched population, hospital mortality occurred in 1.63% of patients in the statin group compared with 2.1% in the no statin group (P = 0.19).

CONCLUSION

These results suggest that previously reported reductions in perioperative mortality for patients taking preoperative statins and undergoing cardiac surgery is likely not mediated through a reduction in postoperative AKI.

Statin use and neurologic morbidity after coronary artery bypass grafting: A cohort study

BACKGROUND

Statin use before surgery has been associated with reduced morbidity and mortality after vascular surgery. The effect of preoperative statin use on stroke and encephalopathy after coronary artery bypass grafting (CABG) is unclear.

METHODS

A post hoc analysis was undertaken of a prospectively collected cohort of isolated CABG patients over a 10-year period at a single institution. Primary outcomes were stroke and encephalopathy. Univariable analyses identified risk factors for statin use, which were applied to a propensity score model using logistic regression and patients were divided into quintiles of propensity for statin use. Controlling for propensity score quintile, the odds ratio (OR) of combined stroke and encephalopathy (primary endpoint), cardiovascular mortality, myocardial infarction, and length of stay were compared between statin users and nonusers.

RESULTS

There were 5,121 CABG patients, of whom 2,788 (54%) were taking statin medications preoperatively. Stroke occurred in 166 (3.2%) and encephalopathy in 438 (8.6%), contributing to 604 patients (11.8%) who met the primary endpoint. The unadjusted OR of stroke/encephalopathy in statin users was 1.053 (95% confidence interval [CI] 0.888-1.248, p = 0.582). Adjustment based on propensity score resulted in balance of stroke risk factors among quintiles. The propensity score-adjusted OR of stroke/encephalopathy in statin users was 0.958 (95% CI 0.784-1.170, p = 0.674). There were no significant differences in cardiovascular mortality, myocardial infarction, or length of stay between statin users and otherwise similar nonusers.

CONCLUSIONS

In this large data cohort study, preoperative statin use was not associated with a decreased incidence of stroke and encephalopathy after coronary artery bypass grafting.

Perioperative statin therapy is associated with a significant and dose-dependent reduction of adverse cardiovascular outcomes after coronary artery bypass graft surgery

OBJECTIVE

The aim of this study was to determine whether perioperative statin therapy was associated with a dose-dependent decrease in adverse cardiovascular events after coronary artery bypass graft (CABG) surgery.

DESIGN

A prospective observational study.

SETTING

A cardiovascular anesthesia unit in a university hospital.

PARTICIPANTS

Four hundred eighteen consecutive patients undergoing CABG surgery between October 2004 and October 2005.

INTERVENTIONS

Patients were divided in 2 groups depending on whether their preoperative treatment included statins or not. In patients receiving statins, high- and low-dose regimens were respectively defined as a regimen recognized to induce a theoretic reduction of low-density lipoprotein cholesterol level equal to 45% (n = 87) or <45% (n = 258). In treated patients, statin therapy was maintained until the day of surgery and was restarted soon thereafter.

MEASUREMENTS AND MAIN RESULTS

The measured endpoint was adverse in-hospital cardiovascular outcomes including heart failure and/or malignant arrhythmia and/or cardiac death. Stepwise logistic regression and a multivariate analysis of propensity-matched cohort were used for analysis of the findings. After adjustment for propensity score, statin therapy was found to produce a significant reduction in cardiovascular outcomes (odds ratio = 0.56; 95% confidence interval [CI], 0.32-0.96, p < 0.05). By using multivariate analysis, the odds ratio for cardiovascular outcomes in patients receiving high-dose statins compared with those treated by low-dose statins was 0.62 (95% CI, 0.41-0.93; p < 0.05).

CONCLUSION

Statin therapy is associated with a significant and dose-dependent reduction in adverse cardiovascular events after CABG surgery. However, further randomized trials still require confirming a causal association between statins and better postoperative outcomes and evaluating the tolerance of such perioperative therapy.

Have statins changed the natural history of atheromatous disease and its treatment?

Statins are among the most widely prescribed medications in the world and there are now numerous clinical trials demonstrating the beneficial effects of these medications on the natural history of atheromatous disease and its treatment. There is now voluminous data to show that patients treated by vascular surgeons benefit from statins and that these medications do effect the natural history of atheroma, its consequences, and treatment. This article will attempt to summarize the more relevant data that highlights the beneficial effects of statins in patients with peripheral arterial disease and how use of these drugs affects cardio-, peripheral, and cerebrovascular risk.

Preoperative statin intake and morbid events after isolated coronary artery bypass grafting

STUDY OBJECTIVE

To examine the effect of statins on morbidity and mortality in patients after isolated coronary artery bypass grafting (CABG).

DESIGN

Observational cohort study.

SETTING

Tertiary-care teaching hospital.

MEASUREMENTS

Data from 2497 adult patients who underwent isolated CABG between January 2002 and June 2004 were studied. Patient characteristics and intraoperative variables were prospectively collected. End points were major morbid events and in-hospital mortality. A propensity score was estimated for each patient using logistic regression on the probability of statin use. Patients were also classified into 5 quintile groups according to their propensity score. Outcome variables were compared for propensity-matched pairs and quintile groups between those who received and did not receive statin therapy.

MAIN RESULTS

Propensity matching resulted in a similar distribution of variables among the 654 matched pairs. Similar perioperative mortality was found between matched pairs with statin therapy vs no statin therapy, 5 (0.76%) and 8 (1.2%), (P = 0.40), respectively. Cardiac, neurologic, renal and respiratory morbidity, occurrence of atrial fibrillation, and length of hospital stay were similar between the matched pairs and among quintiles of propensity scores.

CONCLUSIONS

Preoperative statin intake did not reduce the frequency of major perioperative morbid events after isolated CABG.

Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30,000 patients

AIMS

To determine the strength of evidence for preoperative statin use for prevention of adverse postoperative outcomes in patients undergoing cardiac surgery.

METHODS AND RESULTS

After literature search in major databases, 19 studies were identified [three RCT (randomized prospective clinical trials), 16 observational] that reported outcomes of 31 725 cardiac surgery patients with (n = 17 201; 54%) or without (n = 14 524; 46%) preoperative statin therapy. Outcomes that were analysed included early all-cause mortality (30-day mortality), myocardial infarction (MI), atrial fibrillation (AF), stroke and renal failure. Odds ratio (OR) with 95% confidence intervals (95%CI) were reported using fixed or random effect models and publication bias was assessed. Preoperative statin therapy resulted in a 1.5% absolute risk reduction (2.2 vs. 3.7%; P < 0.0001) and 43% odds reduction for early all-cause mortality (OR 0.57; 95%CI: 0.49-0.67). A significant reduction (P < 0.01) in statin pretreated patients was also observed for AF (24.9 vs. 29.3%; OR 0.67, 95%CI: 0.51-0.88), stroke (2.1 vs. 2.9%, OR 0.74, 95%CI: 0.60-0.91), but not for MI (OR 1.11; 95%CI: 0.93-1.33) or renal failure (OR 0.78, 95%CI: 0.46-1.31). Funnel plot and Egger's regression analysis (P = 0.60) excluded relevant publication bias.

CONCLUSION

Our meta-analysis provides evidence that preoperative statin therapy exerts substantial clinical benefit on early postoperative adverse outcomes in cardiac surgery patients, but underscores the need for RCT trials.

The Role of Statin Drugs in the Management of the Peripheral Vascular Patient

The impact of statin therapy on established vascular conditions and recurrent disease is most relevant for long-term care. Patients receiving statin therapy have been shown to experience less recurrent stenosis following carotid endarterectomy and stent angioplasty, reduced cardiac events following cardiac and noncardiac vascular surgery, and reduction in aneurysm development. In patients with peripheral arterial disease, claudication distance is increased, as well as patency rates following infrainguinal arterial bypass grafting. Of note, statins drugs may also prove beneficial in the prevention of certain cancers, Alzheimer's disease, and osteoporosis (all diseases frequently seen concurrently in the patient with peripheral arterial disease). As such, it is becoming all the more necessary that vascular surgeons remain informed about clinical research initiatives related to statin use and lipid management in general. The following is a review of lipid metabolism as it applies to statins as well as a review of the beneficial effects of statins.

Review article: The role of statins in reducing perioperative cardiac risk: physiologic and clinical perspectives

PURPOSE

To review the pathobiology and clinical implications of coronary vulnerable atherosclerotic plaques (VAPs), to discuss the role of statin therapy in VAP stabilization, and the potential benefits of perioperative statin therapy (PST) in reducing perioperative risk of acute coronary syndromes (ACSs).

SOURCE

MEDLINE search using "perioperative", "cardiac morbidity", "atherosclerosis", "vulnerable plaque", "statins" and combinations of these terms as keywords. The reference lists of relevant articles were further reviewed to identify additional citations.

PRINCIPAL FINDINGS

The nonstenotic, yet rupture-prone VAP causes most myocardial infarctions (MIs) and other ACSs, both in the nonsurgical and surgical patients. Large clinical trials in both primary and secondary prevention and in patients with ACSs have demonstrated that statin therapy will reduce cardiovascular morbidity and mortality across a broad spectrum of patient subgroups. These trials also suggest, and laboratory investigations establish, that statins possess favourable vascular effects independent of cholesterol reduction. Statins appear to interfere specifically with the pathophysiologic mechanisms implicated in atherothrombotic disease. Statins reduce vascular inflammation, improve endothelial function, stabilize VAPs, and reduce platelet aggregability and thrombus formation. Recent studies have shown that PST is associated with a reduced incidence of perioperative and long-term cardiovascular complications in high-risk patients. Combined therapy with statins and ss-blockers is a conceptually valid strategy targeting critical steps in the pathogenesis of an ACS.

CONCLUSION

Emerging evidence for the efficacy and safety of PST is promising, especially when combined with ss-blocker therapy in patients at highest risk. Confirmation of this early evidence awaits the results of ongoing and future prospective randomized controlled trials.