Short-, mid-, and long-term benefits of peri-procedural high-intensity statin administration in patients undergoing percutaneous coronary intervention

Reduction of Vascular Inflammation, LDL-C, or Both for the Protection from Cardiovascular Events?

BACKGROUND

Low density lipoprotein cholesterol (LDL-C) and low grade arterial inflammation are key pathogenic factors for atherosclerosis and its manifestation, cardiovascular disease (CVD).

OBJECTIVE

In this narrative review we assessed if decreasing LDL-C levels or inflammation or both is more effective in reducing CVD events.

RESULTS

In the Scandinavian Simvastatin Survival Study (4S), all statin trials of the 90s' and the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) the benefit came from the LDL-C reduction. In the GREak and Atorvastatin Coronary heart disease Evaluation (GREACE), the Treating to New Targets (TNT), and the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trials both mechanisms in combination produced significant benefits. In the Atorvastatin for Reduction of MYocardial Damage during Angioplasty (ARMYDA) trials and the Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) with a human antibody targeting IL-1β with no lipid lowering effect, the reduction in arterial inflammation played the only beneficial role because there was no change in lipids levels.

CONCLUSION

Both LDL-C and inflammation reduction are beneficial to the reduction of CVD risk. However, canakinumab is a very expensive drug that only induced a 15% reduction in CVD events, thus drastically reducing the possibility for it to be used in clinical practice. Besides, canakinumab is associated with increased infections, some fatal. A potent statin with anti-inflammatory effects is probably the best choice for the majority of those needing hypolipidaemic drug therapy.

Long-term statin use before primary percutaneous coronary intervention improves treatment outcomes of acute myocardial infarction

Numerous studies have reported that high-dose statin loading therapy prior to primary percutaneous coronary intervention (PPCI) improves the clinical outcomes of patients following acute myocardial infarction (AMI). However, little is known about the effects of long-term statin use prior to PPCI on such outcomes. Therefore, the aim of the present analysis was to clarify the effects of long-term statin use before PPCI on the treatment outcomes of patients following AMI. The records of 213 patients who had AMI and met the inclusion criteria were retrospectively reviewed. Patients were divided into two groups: A control group (n=178) who had received no statin pretreatment before AMI onset, and a statin group (n=35) who had received statin treatment for ≥1 month before AMI onset. All patients received a standard treatment regimen for the secondary prevention of coronary artery disease after PPCI. Baseline clinical variables, details of the PPCI procedure and clinical outcomes within 3 months after treatment were reviewed. Patients in the statin group were significantly older than those in the control group (P=0.003). Compared with the control group, there was a greater proportion of patients with hyperlipidemia and previous angina pectoris in the statin group. There were no differences in the use of other drugs (aspirin, β-blockers and angiotensin-converting enzyme inhibitors) prior to PPCI between the two groups. The corrected TIMI frame count (cTFC) was significantly lower in the statin group than in the control group (24.1±12.8 vs. 29.4±14.3, respectively; P=0.043). Multivariable linear regression analysis showed that long-term statin use before AMI was a significant predictor of cTFC after PPCI (P=0.012). Furthermore, the incidence of major adverse cardiac events within 3 months after PPCI was higher in the control group than in the statin group (16.8 vs. 2.9%, respectively; P=0.032). Logistic regression analysis showed that previous statin use was associated with the incidence of major adverse cardiac events within 3 months after treatment (P=0.012). The results of the present study demonstrate that long-term statin use prior to PPCI improved treatment outcomes after AMI in actual clinical practice.

Contrast-Induced Acute Kidney Injury in Patients Undergoing Carotid Artery Stenting: An Underestimated Issue

Carotid artery stenting (CAS) is increasingly offered to patients with carotid artery stenosis. Although CAS is a less invasive (and thus more attractive) alternative compared with carotid endarterectomy, it requires the use of contrast material. A possible side effect from the use of contrast material during CAS is the development of contrast-induced acute kidney injury (CI-AKI). This review discusses the incidence/prevalence and clinical significance of CI-AKI developing after CAS. We also discuss possible measures to reduce the incidence of CI-AKI after CAS.

Statins can improve proteinuria and glomerular filtration rate loss in chronic kidney disease patients, further reducing cardiovascular risk. Fact or fiction?

INTRODUCTION

The prevalence of chronic kidney disease (CKD), a risk factor for cardiovascular disease (CVD), is increasing worldwide. Statin treatment, the cornerstone of prevention or treatment of CVD, might have beneficial effects on urine protein excretion and renal function as determined by the glomerular filtration rate, whereas it might protect from acute kidney injury (AKI), mainly due to contrast-induced AKI. These beneficial effects on CKD may not be drug class effects; specific statins at specific doses may help prevent CKD deterioration and reduce CVD risk. We analysed all statin studies that had renal and CVD endpoints as main outcome measures. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched up to February 2015.

AREAS COVERED

We consider the effects of statins on microalbuminuria, proteinuria, glomerular filtration rate, AKI associated with angiography or percutaneous coronary intervention and on CVD event rates in patients with CKD.

EXPERT OPINION

Current evidence points towards the need to prescribe high-potency statins in patients with CKD, before a major decline in kidney function occurs. This may reduce CVD risk and delay the progress of CKD. Administration of either atorvastatin or rosuvastatin can prevent contrast-induced AKI before angiography or percutaneous coronary intervention. The combination of simvastatin + ezetimibe may decrease vascular events in patients with advanced CKD.