The efficacy of statin administration prior to elective PCI in reducing the incidence of post-procedural myocardial infarction or all-cause mortality: a systematic review
Background: Observational studies show that statin-naïve patients presenting with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI) have significantly higher rates of myocardial infarction (MI) and mortality. We plan to review the evidence for giving statin naïve patients statins 24 hours pre-PCI, with the aim of reducing post-procedural MI and mortality.
Objective: To critically evaluate and appraise primary and secondary literatures that investigate the efficacy of pre-treatment loading of a statin in improving outcome for patients with ACS undergoing percutaneous coronary intervention (PCI).
Review Question: What is the efficacy of statin administration prior to elective PCI in reducing the incidence of post-MI or all-cause mortality?
Methods: We searched the Cochrane Database of Systemic Reviews for systemic reviews and NICE CKS database for relevant NICE clinical guidelines. We then searched the MEDLINE database and Cochrane Central Register of Controlled Trial (CENTRAL) for relevant randomised control trials (RCTs). Our search was limited to peer reviewed papers published in the last 10 years, between 1st February 2006 to 1st February 2016. Our exclusion criteria were as follows: patients previously on statin therapy; statin administration outside 24 hours of PCI; unsuitable outcomes measured; papers not available in full and non-randomised trials. We conducted a systematic review on eligible papers acquired from this search.
Results: Our literature search yielded 86 papers. After reviewing these papers, 80 papers were excluded. Six papers were included in the final review in which 2207 patients received either high-dose statin treatment (n=1111) or placebo/usual care (n=1096). The ARMYDA-ACS trial showed that short-term pre-treatment with atorvastatin reduces the incidence of major cardiac events in patients with acute coronary syndromes undergoing elective PCI (OR=0.12, CI: 0.05-0.50; p=0.004). These findings were consistent with NAPLES II Trial in which preloading with atorvastatin reduced the risk of MI (OR=0.56 CI: 0.35-0.89). On the other hand, the ALPACS trial showed atorvastatin preloading had no significant benefits over usual care. They found that preloading with atorvastatin was not statistically significant reducing for post-procedural MI (OR=0.92, CI: 0.50-1.69) or mortality (OR=1.06, CI: 0.07-17.01). Three papers reported that the use of rosuvastatin given prior to elective PCI was associated with a significant reduction in post-procedural MI in patients. These were Yun KH. et al. (OR=0.50, CI: 0.25-0.98), Wang Z. et al. (OR=0.31, CI: 0.10-0.91) and Cay S. et al. (OR=0.05, CI: 0.01-0.41).
Conclusion: 5 out of the 6 studies reviewed showed supported the effectiveness of pre-procedural statins use in reducing the risk of post-procedural major cardiac events in patients undergoing elective PCI. These findings support routine use of statins in patients with ACS undergoing elective PCI.
(2) Timmis A. Acute coronary syndromes. BMJ Oct 2015; 351: h5153. http://www.bmj.com/content/351/bmj.h5153
(3) National Institute for Health and Care Excellence. Quality standard for acute coronary syndromes (including myocardial infarction). (Quality standard QS68.) 2014. www.nice.org.uk/guidance/qs68.
(4) Grech E. Percutaneous coronary intervention. II: The procedure. BMJ. 2003; 326(7399):1137-1140. http://www.bmj.com/content/326/7399/1137
(5) Spencer F. Association of Statin Therapy with Outcomes of Acute Coronary Syndromes: The GRACE Study. Annals of Internal Medicine. 2004;140(11):857.
(6) Chan A. Early and Sustained Survival Benefit Associated With Statin Therapy at the Time of Percutaneous Coronary Intervention. Circulation. 2001;105(6):691-696. http://circ.ahajournals.org/content/105/6/691.long
(7) Yun K, Shin I, Shin S, Choi J, Kim S, Rhee S et al. Effect of Previous Statin Therapy in Patients With Acute Coronary Syndrome and Percutaneous Coronary Intervention. Korean Circulation Journal. 2011;41(8):458. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3173666/
(8) Patti G, Cannon C, Murphy S, Mega S, Pasceri V, Briguori C et al. Clinical Benefit of Statin Pretreatment in Patients Undergoing Percutaneous Coronary Intervention: A Collaborative Patient-Level Meta-Analysis of 13 Randomized Studies. Circulation. 2011;123(15):1622-1632. http://circ.ahajournals.org/content/123/15/1622.long
(9) Patti G, Pasceri V, Colonna G, Miglionico M, Fischetti D, Sardella G, et al. atorvastatin pre-treatment improves outcomes in patients with acute coronary syndromes undergoing early percutaneous coronary intervention: results of the ARMYDA-ACS randomized trial. J Am Coll Cardiol 2007 Mar 27; 49(12):1272-1278. http://www.ncbi.nlm.nih.gov/pubmed/17394957
(10) Yun KH, Jeong MH, Oh SK, Rhee SJ, Park EM, Lee EM, et al. The beneficial effect of high loading dose of rosuvastatin before percutaneous coronary intervention in patients with acute
coronary syndrome. Int J Cardiol 2009 Nov 12; 137(3):246-251.
(11) Wang Z, Dai H, Xing M, Yu Z, Lin X, Wang S, et al. Effect of a single high loading dose of rosuvastatin on percutaneous coronary intervention for acute coronary syndromes. J Cardiovasc Pharmacol Ther 2013 Jul; 18(4):327-333.
(12) Jang Y, Zhu J, Ge J, Kim YJ, Ji C, Lam W. Preloading with atorvastatin before percutaneous coronary intervention in statin-naive Asian patients with non-ST elevation acute coronary syndromes: A randomized study. J Cardiol 2014 May; 63(5):335-343. http://www.journal-of-cardiology.com/article/S0914-5087%2813%2900291-8/fulltext
(13) Briguori C, Visconti G, Focaccio A, Golia B, Chieffo A, Castelli A, et al. Novel approaches for preventing or limiting events (Naples) II trial: impact of a single high loading dose of atorvastatin on periprocedural myocardial infarction. J Am Coll Cardiol 2009 Dec 1; 54(23):2157-2163.
(14) Cay S, Cagirci G, Sen N, Balbay Y, Durmaz T, Aydogdu S. Prevention of peri-procedural myocardial injury using a single high loading dose of rosuvastatin. Cardiovasc Drugs Ther 2010 Feb; 24(1):41-47.
(15) Ge J, Kim YJ, Jang YS, Zhu J, Marschner IC, Lam W. Design and rationale of astudy in Asia of atorvastatin pretreatment in patients undergoing percutaneous coronary intervention for non-ST elevation acute coronary syndromes. J Cardiol 2010; 55:303–8. http://www.journal-of-cardiology.com/article/S0914-5087%2809%2900346-3/fulltext
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