High-Dose Statins before PCI Improved Outcomes in NSTE-ACS

San Francisco, CA—Statin use before PCI reduced clinical events by more than 40% in a cohort of patients with non-ST elevation acute coronary syndromes.

Georges Elias El-Hayek, MD, of St. Luke's Roosevelt Hospital Center in New York, and colleagues, performed a meta-analysis of RCTs of statin loading prior to PCI in statin naïve patients presenting with stable angina or NSTE-ACSI. “Compared to a prior meta-analysis in 2011, we limited our inclusion criteria to statin naive patients and to placebo in the control arm to examine the net effect of statin loading,” he said.

In the current meta-analysis of 1,188 review articles and 15 randomized controlled trials, researchers aimed to investigate whether statin loading before PCI may reduce peri-procedural MI. The cohort included 3,529 stable patients and individuals with non-ST elevation acute coronary syndromes (NSTE-ACS).

Outcome measures included major cardiac events such as death, spontaneous MI, target vessel revascularization and stent thrombosis.

The researchers compared outcomes for 1,783 patients who received a loading dose of statins before PCI and 1,746 patients in whom statins were initiated after PCI.

Pre-procedural statin use yielded a 43% reduction in clinical events during follow-up (OR=0.57; 95% CI, 0.37-0.89; P=.01). The reduction remained significant only among individuals with NSTE-ACS (OR=0.18; 95% CI, 0.07-0.47; P=.0005) when the population was stratified by clinical presentation. No reduction was observed in patients who underwent PCI to treat stable angina (OR=1.0; 95% CI, 0.58-1.72; P=NS).

“Given the continuous updates in the definition of peri-procedural myocardial infarction and the controversy regarding its prognosis, and contrary to the prior meta-analysis where the cardiovascular benefits of statin loading were driven by a reduction in peri-procedural MI, we were able to demonstrate a strong reduction in clinical events including the combined endpoint of death, spontaneous myocardial infarction or target lesion revascularization,” El-Hayek said. “This clinical benefit of statin loading prior to PCI appeared to be significant only for those patients with NSTE-ACS.”

PubMed and Scopus database results from 1966 to March 2013 were included in the analysis. The investigators aimed to test the hypothesis that peri-procedural MI may decline with statin loading before PCI.

Study protocols dictated a fixed effect analysis when the I2 was up to 40% and the P value reached at least .10, according to the results. Otherwise, a random effect was employed.

“Although the ACC/AHA Guidelines for the Management of NSTE-ACS advocate the initiation of statin therapy before discharge, they do not specify the timing of its initiation,” El-Hayek said. “The results from our analysis would support early and aggressive statin therapy prior to PCI specifically in patients with NSTE-ACS to improve clinical outcomes.”