Perioperative Statin Therapy Improves Clinical Outcomes Following CABG Surgery

Perioperative statin therapy, started anywhere from a week to 21 days before surgery, significantly improves clinical outcomes following CABG surgery, according to the results of a new review.

While the use of statins before and after surgery significantly reduced the risk of A-fib, as well as appeared to reduce the short-term risk of all-cause mortality, researchers say the lipid-lowering drugs are frequently stopped in patients undergoing CABG surgery. 

“In the literature, among the patients going for bypass surgery, there is a practice among surgeons that has them discontinue the medication out of concerns for side effects,” senior investigator Islam Elgendy, MD, University of Florida in Gainesville, told TCTMD. “We conducted the review to look at the benefits and hazardous events that might happen when using statins for patients undergoing bypass surgery.”

In their review published January 12, 2016, in the Annals of Thoracic Surgery, the researchers note that 1 study of 9,284 patients found just over one-third of patients were taking a statin in the year leading up to the CABG while another found statins were used in less than 10% of patients on the day of CABG surgery. These results are in line with other data suggesting statins remain underused even in patients with established CAD, despite the current American College of Cardiology/American Heart Association guidelines recommending statins for the treatment of coronary disease. 

Regarding A-fib, the reviewers highlight the ARMYDA-3 study, a 200-patient trial showing the use of atorvastatin 40 mg prescribed 7 days prior to surgery reduced the risk of postoperative A-fib by 61%. Trials testing rosuvastatin (Crestor; AstraZeneca) were mixed, with 1 small trial showing a reduction in A-fib with rosuvastatin 20 mg and another large study, the 1,922-patient STICS trial, failing to show a benefit. Elgendy said either rosuvastatin doesn’t reduce A-fib, or patients didn’t get the drug in time before surgery. In STICS, statin loading took place 8 days before surgery compared with other trials that utilized a 14- or 21-day run-in. 

In a meta-analysis of 12 randomized, placebo-controlled trials that was conducted by Elgendy and published in 2015 in the American Journal of Cardiology, starting statins before surgery was associated with a 58% lower risk of postoperative A-fib. Although the meta-analysis included STICS, Elgendy said the A-fib benefit was mostly seen in trials testing atorvastatin 20 mg or 40 mg. 

In addition to reducing the risk of A-fib, the data hints at a mortality benefit with the perioperative use of statin therapy. Multiple single-center observational studies showed the use of statins reduced the risk of mortality post-CABG, with estimates ranging from a 43% reduction in in-hospital mortality in 1 analysis to a 47% reduction in early mortality after CABG in another. Analysis of 16,000 patients included in a European registry found that preoperative statin use was the only medication associated with a reduction in postoperative mortality, a reduction not seen with other medications, including beta blockers and ACE inhibitors, report investigators.

To TCTMD, Elgendy said the guidelines make no reference to stopping statins prior to CABG but, even so, surgeons will stop the drugs out of potential concerns for muscle spasm or rhabdomyolysis after the procedure. However, he believes the data are sufficiently strong enough for physicians to continue with the medication. “If the patient is on a statin, we would recommend they continue taking it before and after the procedure,” said Elgendy. “If they’re not on a statin, and they’re going for the surgery, we would also recommend they start it.”

As for the benefits of statins beyond CABG, Elgendy said there are data suggesting that statin preloading could reduce the risk of periprocedural MI in PCI but emphasized that the current analysis did not specifically address this question. In their review, the researchers did not find statin therapy reduced the risk of MI after CABG, nor did the drugs appear to provide any protection to the kidney. The reviewers did observe a reduction in postoperative stroke/TIA with statins, but the benefit may be attributable to the reduction in postoperative A-fib, they say.  

Source:
Barakat AF, Saad M, Abuzaid A, et al. Perioperative statin therapy for patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2016;Epub ahead of print. 

Disclosures:

• Elgendy reports no conflicts of interest. 

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