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Statins to Prevent Perioperative Cardiovascular Events

In high-risk patients, several weeks of statin therapy before vascular surgery led to less ischemia and fewer MIs.

Rupture of coronary plaque probably accounts for half of perioperative myocardial infarctions. Because statins have plaque-stabilizing effects, they are plausible candidates for preventing perioperative MIs.

In the industry-supported DECREASE-III trial, Dutch researchers randomized 497 statin-naive patients scheduled for elective vascular surgery (carotid, aortic, or lower extremity) to receive daily extended-release fluvastatin (80 mg) or placebo. Fluvastatin was started at least several weeks before surgery and was continued for 1 month postoperatively. Patients were at high risk: 28% had suffered previous MIs, 38% had experienced previous cerebrovascular events, 57% were hypertensive, and 20% had diabetes.

The primary endpoint, myocardial ischemia (defined as transient electrocardiographic changes or release of troponin T) within 30 days after surgery, occurred significantly less often in the fluvastatin group than in the placebo group (11% vs. 19%, P=0.01). A secondary endpoint (nonfatal MI or cardiovascular-related death) also occurred less often with fluvastatin (5% vs. 10%, P=0.03). No rhabdomyolysis or other side effects were reported.

Comment: In this study, statins were associated with better outcomes, without any apparent adverse effects. However, the primary endpoint (ischemia) is softer and less clinically relevant than the secondary endpoint. Moreover, most of these high-risk patients probably should have been taking statins long-term, regardless of their need for vascular surgery. Because of these caveats, and because fluvastatin was not associated with significantly better perioperative outcomes in a recent study of lower-risk patients (JW Gen Med Jun 18 2009), the benefits of initiating statins preoperatively should be validated in additional studies.

— Allan S. Brett, MD

Published in Journal Watch General Medicine September 3, 2009

Citation(s):

Schouten O et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med 2009 Sep 3; 361:980.

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• Statins to Prevent Perioperative Cardiovascular Events
  Haja nazimuddin, 9 Sep 2009 8:01 AM EST
  were the placebo group not on statin therapy before the trial? If not it is surprising. If yes, was the... [more]