TCTMD: Statins More Beneficial Before PCI Than After in ACS Patients

Key Points:

  • Meta-analysis examines efficacy of statin administration pre- vs post-PCI
  • Pre-PCI statin initiation associated with lower mortality, MI at 30 days
  • Statins at any time better than no or low dose, authors say

SOURCE

By Meghann Lucy
Monday, March 10, 2014

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Giving statins before percutaneous coronary intervention (PCI) lowers the risk of 30-day events compared with post-PCI initiation or no or low-dose statins in patients with acute coronary syndromes (ACS), according to a meta-analysis published online March 3, 2014, ahead of print in The American Journal of Cardiology. Long-term results also confirm the benefits of any statin use for this indication.

The meta-analysis, led by Eliano Pio Navarese, MD, PhD, of Radboud University Nijmegen Medical Center (Nijmegen, the Netherlands), included 20 randomized clinical trials amassing 8,750 ACS patients. Trial designs varied, with patients randomized to statin therapy (before or after PCI) or standard care (low-dose or no statins). Results were stratified by statin administration either pre- or post-PCI.

Statins were initiated a mean of 1.43 (SD 3.2) days after ACS presentation, specifically 0.53 ± 0.42 days before intervention in the pre-PCI group and 3.18 ± 3.56 days after in the post-PCI group. Primary endpoints were 30-day all-cause mortality and MI, and secondary endpoints were MACE (CV death, MI, and TVR) and MACCE (death, nonfatal MI and nonfatal stroke).

On meta-regression analysis, a strong linear correlation was found between early initiation of statins and reduced rates of MI at 30 days. Mortality, both at 30 days and beyond, as well as long-term MI, showed trends in the same direction (table 1).

Table 1. Event Risk: Pre- and Post-PCI Statin vs No/Low-dose Statin

OR

CI 95%

P Value

Mortality (30 d)
Before
After

0.36
0.73

0.11-1.23
0.45-1.17

0.10
0.19

Mortality (> 30 d)
Before
After

0.42
0.80

0.11-1.62
0.57-1.13

0.21
0.21

MI (30 d)
Before
After

0.38
0.85

0.24-0.59
0.64-1.13

< 0.0001
0.28

MI (> 30 d)
Before
After

0.32
0.83

0.08-1.36
0.66-1.03

0.12
0.10

Further analyses showed a positive relationship between early statin administration and reductions in MI-driven MACE and MACCE at 30 days.

Thirty-day mortality was 0.91% with any statin use and 1.41% in the no/low-dose statin group; whereas, MI rates were 3.40% in the statin group and 5% in the no/low-dose group at 30 days. Statin use vs control also resulted in lower 30-day occurrence of MACE at 5.29% and 8.17%, respectively (table 2).

Table 2. Thirty-Day Event Risk: Any Statin vs No/Low-dose Statin

OR

CI 95%

P Value

Mortality

0.66

0.43-1.02

0.06

MI

0.67

0.53-0.84

0.0007

MACE

0.35

0.20-0.59

0.0001

MACCE

0.78

0.61-0.99

0.04

Beyond 30 days, results remained consistent between the statin and no/low-dose statin groups.

Timing Key

In an email with TCTMD, Dennis Ko, MD, MSc, of the Sunnybrook Health Sciences Centre (Toronto, Canada), said the meta-analysis is “consistent with existing knowledge that statin use prior to and after PCI is important.” Uniquely, it indicates that “giving statins before PCI is even more important than giving it to them after,” he stressed.

According to the authors, the meta-analysis is the first to focus on ACS and the timing of statin use in conjunction with PCI.

But is Use Before PCI Plausible?

In an email with TCTMD, Gennaro Sardella, MD, of “Sapienza” University of Rome (Rome, Italy), raised the issue that physicians’ unfamiliarity with the benefits of statins may be an obstacle to universal pre-PCI statin use, noting a potential overreliance on “antiplatelet therapy as the unique therapy in revascularization.”

“We could take into consideration administrating a statin loading dose at least in high-risk patients treated with PCI,” Dr. Sardella posited.

Dr. Ko believes widespread pre-PCI statin use is possible in ACS/AMI patients. “But for many stable CAD patients, physicians want to wait for the anatomy to see if there is a lesion and to see whether a statin is useful or not,” he explained.

The current study “reinforces the need for statins before PCI,” Dr. Ko said, adding. “It is reasonable for a physician to start on therapy prior to cath. Should the patient end up not having any blockages or not be a good candidate for statins, you can always stop.” 

Study Details

Though several different types of statins were used in the various trials included in the meta-analysis, sensitivity testing revealed homogeneous benefits. In-line with conventional recommendations, high-dose statins were predominately administered.

 


Source:
Navarese EP, Kowalewski M, Andreotti F, et al. Meta-analysis of time-related benefits of statin therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Am J Cardiol. 2014;Epub ahead of print.

 

Disclosures:

  • Drs. Navarese, Ko, and Sardella report no relevant conflicts of interest.
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