Benefits of Perioperative Statins Borne Out in Trial



CHICAGO – Results from a follow-up analysis of patients in the randomized DECREASE III trial showed that there is an apparent "legacy" effect of perioperative statin therapy, resulting in improved long-term survival, compared with statin initiation after vascular surgery.

Ischemic cardiac events are a major cause of perioperative morbidity and mortality in noncardiac surgery (including vascular surgery), with an estimated 10%-40% of perioperative deaths ascribed to myocardial infarction (MI), according to the original report by Dr. Don Poldermans and the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) III researchers. Statins, which are associated with improved plaque stability, were plausible candidates to reduce perioperative MI. And in fact, results of the original DECREASE III study showed that in high-risk patients who undergo major vascular surgery, fluvastatin XL reduced myocardial ischemia and the combined end point of cardiovascular death and MI.

Dr. Olaf Schouten from the Erasmus University Medical Center, Rotterdam, the Netherlands, discussed a further analysis of the DECREASE III population at the Vascular Annual Meeting. The investigators examined a total of 497 patients who were randomized to placebo (247 patients) or fluvastatin (250) in the double-blinded trial.

The patients had been started on treatment a median of 34 days prior to surgery. At the end of the DECREASE III study period (30 days after surgery), all patients were prescribed lifelong statins as recommended by current guidelines. The current study relied on all-cause death data obtained from a civil service registry for a median follow-up of 4.8 years, during which time 129 patients died.

Perioperative statin use was associated with a significant reduction of perioperative cardiovascular events (hazard ratio, 0.55), according to Dr. Schouten. In a multivariate analysis that adjusted for possible confounders including cardiovascular risk factors, type and site of vascular surgery, and age, preoperative statin initiation was still significantly associated with an improved long-term outcome (HR, 0.59).

"The randomized DECREASE III trial showed that perioperative statin use is associated with a significant reduction of perioperative cardiovascular events," according to Dr. Schouten. But it appears that statin therapy also results in a long-term survival benefit, compared with postoperative initiation of statin therapy, he added.

"This ‘legacy’ effect might be due to the prevention of perioperative myocardial damage, as patients with myocardial damage had a significantly higher risk of death during follow-up," Dr. Schouten speculated.

"The main message of our study is that all vascular surgery patients eligible for statin therapy [that is, without contraindications] should be prescribed statins at the first, preoperative, and outpatient clinic visit," said Dr. Schouten in an interview. He pointed out that statin therapy is safe in the perioperative period, with no significant side effects; it improves perioperative cardiac outcome; and it is associated with a long-term survival benefit.

"So prescribe statins as soon as possible, keep them on statins in the perioperative period, and keep them on [lifelong statins] after surgery," Dr. Schouten concluded.

Dr. Schouten stated that he had nothing to disclose.

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