Decrease III: Statin Fun!

We have been using statins to reduce perioperative cardiac events on the inpatient service for quite a while. The reality is, the data on its use in this situation is sparse. The best study is too small and didn’t actually reach statistical significance (although a trend towards benefit) (Lipitor with Vascular Surgery.pdf). It was also studied on patients undergoing vascular surgeries, not in grandpa’s hip replacement. 

All of this hasn’t stopped us from starting statins, and apparently was enough (with the help of a few meta-analysis) for the ACC/AHA to recommend them during the perioperative time (Class IIa: Reasonable for all patients undergoing vascular surgery; Class IIB for all with at least 1 risk factor undergoing intermediate risk surgery).

This week int the NEJM, another study has come out on preoperative statins (Decrease III) (Decrease III- Preoperative Statin.pdf). In this double blind, placebo controlled study, they looked at fluvastatin vs placebo in reducing perioperative cardiac events on patients having vascular surgery. The study appears to be well designed, and is much better powered than the prior statin study (although still small: around 250 in each group). The treatment arm was placed on fluvastatin 80mg daily for an average of 37 days. The results are not surprising, again showing significant benefit. Briefly, cardiac death was reduced (4.8% in the fluvastatin gropu vs 10.1% in placebo) and myocardial ischemia was reduced (10% vs 10.8%). All excellent results.

So the question is why? 

While it not surprising, LDL was reduced on the fluvastatin arm (around 24% reduction), but I find it unlikely this was the mechanism that fluvastatin reduced events. CRP was also reduced (20% reduction) with fluvastatin. I think this is the mechanism of action: reduction of inflammation and plaque stabilization. A recent study demonstrated benefit in loading a statin prior to cardiac cath (Efficacy of Atorvastatin Roloading.pdf), suggesting to me that the plaque stabilization effect maybe immediate. 

So for now, I will continue giving statins preoperatively, even when started on day of surgery. Perhaps one day CVAs, MIs will be treated with a stat asa and a stat statin.
For now, the evidence for periopeartive statins is stronger.