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

Abstract

Abstract

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.