30 Clinical
Pharmacy Practice News • October 2010
Cardiology
Statin ‘Loading’ Cuts Post-op MI Risk Stockholm—Statins given before invasive procedures such as percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery and noncardiac surgery significantly reduce the risk for post-procedural myocardial infarction (MI), and also lower the risk for atrial fibrillation after CABG, a new meta-analysis has shown. The findings suggest that clinicians should consider using statins routinely before performing such procedures,
‘If I am seeing someone in clinic for evaluation of angina, I’ll start [him or her] on at least 40 mg of atorvastatin in anticipation of catheterization.’ —Anthony A. Bavry, MD, MPH according to the senior author, Anthony A. Bavry, MD, MPH, director of the Gainesville VA Medical Center cath-
eterization laboratory and assistant professor of medicine at the University of Florida, Gainesville. Dr. Bavry pre-
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sented the results of the meta-analysis at the 2010 European Society of Cardiology Congress in Stockholm. The study was published simultaneously online in the Journal of the American College of Cardiology (2010;56:doi:10.1016/j. jacc.2010.04.023). “There have been a number of individual studies that have been published examining the role of statin therapy before invasive procedures, but there has not been a comprehensive meta-analysis on the topic, so we wanted to gather together all of the individual studies and see what the benefit might be from this approach,” Dr. Bavry told Pharmacy Practice News. The meta-analysis, which comprised 21 trials and 4,805 patients, showed that use of pre-procedural statins reduced post-procedural MI (risk ratio [RR], 0.57; 95% confidence interval [CI], 0.46-0.70; P<0.0001). The benefit was seen after PCI (P<0.0001) and noncardiac surgical procedures (P=0.004), but not CABG (P=0.40). Post-procedural atrial fibrillation after CABG also was reduced (RR, 0.54; 95% CI, 0.43-0.68; P<0.0001). Statin therapy was also shown to reduce allcause mortality, albeit nonsignificantly (RR, 0.66; 95% CI, 0.37-1.17; P=0.15).
Questions Remain, But Results Still Practice-Changing “The optimal timing, dose and type of statin are unclear from these studies, because there was a lot of variability between the studies,” Dr. Bavry said. “However, we tried to distill down the common characteristics. For PCI, we found it was atorvastatin at a dose of 40 to 80 mg, one to seven days before the procedure. For the noncardiac surgical procedures, it was fluvastatin at a dose of 80 mg per day, given four weeks before the surgery.” Dr. Bavry said he is now incorporating the findings into his own practice. “If I am seeing someone in clinic for evaluation of angina, I’ll start [him or her] on at least 40 mg of atorvastatin in anticipation of catheterization,” he explained. “However, if I’m seeing [the patient] the day of or the day before the procedure, I’m going to start atorvastatin 80 mg. And for the other category of patients who come in already on statin therapy, we’ve begun giving them a booster dose