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Perioperative statins improve cardiac outcomes of vascular surgery

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Treatment with fluvastatin both before and after vascular surgery decreases the incidence of cardiovascular death and myocardial infarction, according to results of a prospective Dutch study.

Besides improving lipid profiles, statins reduce inflammation, Dr. Don Poldermans and associates note in the New England Journal of Medicine for September 3. They theorized that fluvastatin might “prevent destabilization of coronary plaque induced by the stress of surgery,” and thereby avert thrombus formation and subsequent vessel occlusion.

In the randomized, double-blind Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) trial, Dr. Poldermans, from Erasmus Medical Center in Rotterdam, and colleagues treated 250 patients with extended-release fluvastatin, 80 mg/d, and 247 with placebo, starting at a median of 37 days before surgery and continuing for at least 30 days afterward.

Subjects were undergoing abdominal aortic aneurysm repair, distal aortoiliac reconstruction, lower-limb arterial reconstruction, or carotid-artery endarterectomy.

The incidence of postoperative myocardial ischemia was reduced by 45% in the fluvastatin group (10.8% vs 19.0% in the placebo group, p = 0.01), according to the authors. They estimate that 12 patients would need to be treated to prevent myocardial ischemia in one.

Fluvastatin was associated with a 53% relative reduction in the composite secondary end point of cardiovascular death or nonfatal myocardial infarction (4.8% vs 10.1%, p = 0.03) within 30 days after surgery. Nineteen patients would need to be treated to prevent the composite end point in one patient.

In the fluvastatin group, 6 patients died, 4 from cardiovascular causes. Of 12 deaths in the placebo group, 8 were from cardiovascular causes.

The authors note that total and low-density cholesterol, as well as interleukin-6 and C-reactive protein, were significantly reduced by the time surgery was performed only in the fluvastatin group.

“The results of the DECREASE III trial suggest that the benefits of perioperative statin use outweigh the risks and that long-term statin therapy in patients with peripheral arterial disease may be prudently initiated during the perioperative period,” the investigators conclude.

N Engl J Med 2009;361:980-989.