A systemic review of existing evidence encourages pre-CABG statin therapy

Barakat AF, Saad M, Abuzaid A, et al.
Ann Thorac Surg 2016;101:818–25

Background

One of the reasons for the increased morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG) is the development of an intense systemic inflammatory response in these patients, which is particularly profound when cardiopulmonary bypass is used [1-3].
Although there is evidence supporting a beneficial role of preoperative statin therapy in weakening this systemic inflammatory response [4,5], in everyday clinical practice, statin discontinuation before CABG is common, in order to avoid possible adverse effects [6].
The benefit of preoperative statin therapy is attributed to their pleiotropic effects that include:

• Anti-inflammatory effect, measured by a significant reduction in serum levels of C-reactive protein [7,8]
• Antithrombotic effect, as a result of the upregulation of nitric oxide, and the decreased production of thromboxane A2 and increased production of prostacyclin [9,10]
• Antioxidant role, through the reduction in LDL oxidation [11]
• Anti-proliferative effect on smooth muscle cells that contributes to the reduction of in-stent restenosis [12]
• Reduction of atherosclerotic plaque neovascularization and macrophage content [13]

This article provides a review of the existing data on the role of perioperative statin therapy and its effect on postoperative outcomes in CABG patients.

Main results

There is clinical evidence supporting that preoperative statin therapy:

• is associated with reductions of in-hospital mortality, operative mortality, and perioperative mortality
• is an independent predictor of in-hospital mortality, particularly in high-risk patients
• decreases the incidence of myocardial infarction after percutaneous coronary intervention and non-cardiac operations, but this effect was not proven in post-CABG patients (a statin reload strategy is currently tested, to recapture this effect)
• is associated with reductions in risk of postoperative atrial fibrillation, if lipophilic statins are used, such as atorvastatin and simvastatin
• is associated with a lower rate of perioperative cerebrovascular events, such as stroke or transient ischemic attack, although this evidence might reflect the decreased incidence of postoperative atrial fibrillation in the statin group of these studies
• is associated with a decreased incidence of postoperative renal insufficiency, a reduced need for postoperative renal replacement therapy mainly in younger and low-risk patients, and a reduction in postoperative acute kidney injury, in observational studies using commercially available statins
• is associated with a shorter mean duration of hospital stay after CABG, and a decrease in the length of intensive care unit stay, probably due to the reduction of postoperative complications
• did not result in an increased risk of postoperative myopathy

Conclusion

Existing evidence supports the preoperative statin therapy in CABG patients, because it leads to improved postoperative outcomes, especially reduced perioperative mortality and atrial fibrillation. The risk for statin related adverse events in this setting of intense systemic inflammatory response is not increased.

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