Statins before procedures reduce cardiovascular events and death

March 24, 2003

DALLAS, March 25 - Taking cholesterol-lowering drugs before undergoing artery-clearing procedures appears to reduce deaths, heart attacks, and recurrent blockages among patients with elevated levels of an inflammation marker, according to research reported in today's rapid access issue of Circulation: Journal of the American Heart Association.

Previous studies have suggested that taking a class of cholesterol-lowering drugs called statins after percutaneous coronary interventions (PCI) such as balloon angioplasty or stenting could lower deaths.

In this study of 1,552 patients, those taking statins before PCI were less likely to have a heart attack during the procedure. They also had a better outcome at one year after the procedure.

The greatest benefit was in statin patients with highly elevated levels of high-sensitivity C-reactive protein (hsCRP) - 1.11 milligrams per deciliter (mg/dL) or higher, says lead investigator Albert W. Chan, M.D., MSc, associate director of the catheterization laboratory, Ochsner Clinic Foundation in New Orleans.

CRP is a marker of systemic inflammation and has been shown to predict cardiac events.

The study, conducted while Chan was working at the Cleveland Clinic Foundation, Cleveland, Ohio, collected data prospectively from patients who underwent elective PCI and who had hsCRP measurements before PCI. They were followed for a year. Researchers found that 39.6 percent of patients were taking a statin before PCI. Their average age was 64, and 27 percent of them were women. Generally, the patients taking statins were younger, more likely to be taking ACE inhibitors and more likely to have a history of coronary bypass surgery and/or multivessel disease.

The patients who were already taking statins before their procedures had lower median hsCRP levels than patients who didn't take statins (0.40 mg/dL versus 0.50 mg/dL).

Moreover, the hsCRP levels of patients were independent of their cholesterol levels.

"Statins appear to have an effect that is independent of their effect on cholesterol," Chan says.

Statin pre-treatment was associated with reduced risk for heart attack during the procedures (5.7 percent versus 8.1 percent); a lower one-year death rate (3.4 percent versus 6.9 percent) and lower non-fatal heart attacks at one year (6.3 percent versus 9.8 percent). The rate of restenosis (reblockage) was much reduced with statin therapy among patients with elevated hsCRP, whereas statins did not affect restenosis among those with normal hsCRP.

In addition, for people with the highest hsCRP levels, statins were associated with 40 percent lower rates of death, heart attacks and revascularization after one year.

"Our study for the first time links the relationship of statin pre-treatment, lowering of inflammation and improvement of death rates, heart attacks and revascularization procedures," he says.

Importantly, this study reports that the benefits of statins were predominantly found in patients with high hsCRP levels only. "While recent clinical studies suggest that patients with coronary heart disease should be started on a statin irrespective of their cholesterol levels, our findings suggest inflammatory status assessed by hsCRP levels may help doctors to prescribe statin therapy more selectively in patients with high hsCRP. This measurement may help in targeting statin therapy," he adds.

While the study findings indicate that statin treatment should start before PCI, Chan says it is uncertain how soon statins should be started before the procedure. However, he says that other studies demonstrated that hsCRP was lowered as early as within two weeks; so he suggests that at least two weeks of treatment are needed.

The study findings suggest that it may be beneficial to delay non-emergency PCI among patients with high hsCRP levels, so these patients can be put on statins for at least two weeks before elective angioplasty procedures.

Currently, the American Heart Association and the Centers for Disease Control and Prevention do not recommend universal CRP testing. In recommendations issued earlier this year, the two organizations suggested that CRP may be useful as a discretionary tool for evaluating patients who are considered at moderate risk.
Co-authors are Deepak L. Bhatt, M.D.; Derek P. Chew MBBS, MPH; Joel Reginelli, M.D.; Jakob P. Schneider, RN; Eric J. Topol, M.D.; and Stephen Ellis, M.D.

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