Boston, MA - More evidence is available supporting the preemptive use of statins in patients undergoing cardiac surgery, only this time the benefit extends to patients without existing coronary artery disease [1].

A new retrospective review, published in the December 2008 issue of the Journal of Thoracic and Cardiovascular Surgery, has shown that the preoperative use of statins is associated with lower mortality among patients undergoing valve surgery.

"Clinically, this study implies that a preemptive use of preoperative statins may improve operative outcomes in patients undergoing cardiac valve surgery who do not have a history of coronary artery disease," write lead investigator Dr Minoru Tabata (Brigham and Women's Hospital, Boston, MA) and colleagues. "Our cohort includes concomitant aortic, congenital, and other cardiac procedures. Combined with previous findings in coronary artery bypass graft and patients with coronary artery disease, the beneficial effects of preoperative statins may be generalizable to most patients undergoing cardiac surgery."

The use of preoperative statin therapy among patients undergoing CABG surgery has been shown to improve operative outcomes in other studies, including a large 30 000-patient meta-analysis published in the June 2008 issue of the European Heart Journal [2]. In that study, previously reported by heartwire, preoperative statins reduced the risk of 30-day mortality from any cause by 40%, as well as significantly reduced the risk of stroke and atrial fibrillation.

As Tabata and colleagues point out, however, the role for preoperative statins in patients without coronary artery disease is less defined.

In this review, the investigators analyzed data from 1389 patients undergoing cardiac valve surgery, excluding those undergoing concomitant CABG surgery and those with a history of MI. Of these patients, 363 were treated with a statin, including 197 who were taking atorvastatin and 126 who were taking simvastatin. More than half of the atorvastatin patients were taking the 10-mg dose, whereas most simvastatin patients were taking either the 20-mg or 40-mg dose.

Patients pretreated with statins prior to surgery had a lower rate of operative mortality—defined as death within 30 days after surgery—than those not taking statins. The rate of death was 0.8% among the statin-treated patients compared with 2.3% for the non-statin-treated group, a difference that translated into a 75% lower risk of death within 30 days. Statin pretreatment had no effect on the risk of stroke or perioperative MI rates.

The pleiotropic effects of statins, including improved endothelial function, enhanced stability of atherosclerotic plaque, decreased oxidative stress and inflammation, and an inhibited thrombogenic response are possible biological mechanisms underlying the beneficial effect, suggest the authors.

"These effects may attenuate the proinflammatory effects of surgical invasiveness and cardiopulmonary bypass," write Tabata and colleagues. Further study, however, is needed to confirm the benefit, as well as to confirm the biological mechanism providing the reduction in mortality, they add.

Another study, also appearing in the December 2008 issue of the Journal of Thoracic and Cardiovascular Surgery, has shown that pretreatment with statins, specifically rosuvastatin (Crestor, AstraZeneca), reduces myocardial damage following cardiac surgery [3].

In total, 200 patients, including those with coronary artery disease, were randomized to rosuvastatin 20 mg or placebo one week before coronary surgery. Troponin I, myoglobin, and creatine kinase-MB mass levels—all markers of myocardial injury—were lower after surgery among patients pretreated with rosuvastatin. High-sensitivity C-reactive protein (hs-CRP) levels were also significantly less elevated; CRP increased 58% in the pretreated statin-therapy arm and 88% in those randomized to placebo.

In their paper, lead investigator Dr Vito Mannacio (University of Naples Federico II, Italy) and colleagues point out that large event-driven studies are needed to assess the advantages of preoperative statin therapy and that other populations, including those with diabetes, unstable patients, and patients with extensive coronary artery disease and decreased left ventricular function, need to be included in future trials.