Reduced HF and Mortality When Statin Started Before First ACS

Quick Takes

  • Use of statins for primary prevention may reduce the risk of acute heart failure (AHF) and early AHF-related mortality for patients presenting with an ACS event as the first signal of atherosclerotic disease.
  • The greatest benefit for primary prevention was observed in patients with 10-year ASCVD risk >10%, supporting USPSTF recommendations.

Study Questions:

Does previous use of statins reduce the prevalence of acute heart failure (AHF) on hospital admission in patients presenting with acute coronary syndromes (ACS) as their first manifestation of atherosclerotic cardiovascular disease (ASCVD)?

Methods:

This study evaluated 14,542 patients from the International Survey of Acute Coronary Syndromes (ISACS-Archives), specifically the ISACS-TC registry (data from 41 centers in 12 European countries) and the EMMACE-3X registry (data from 47 hospitals in England). Eligible patients had clinically confirmed ACS and were excluded if they had a prior history of ASCVD (history of stroke, angina, myocardial infarction, heart failure, prior revascularization, or peripheral arterial disease). Patient characteristics were stratified according to treatment group of statin users versus nonstatin users. The key outcome measure was the prevalence of AHF (based on Killip class) on admission for ACS as the index presentation of ASCVD. Other outcomes included the association of AHF with all-cause mortality at 30 days from admission and the role of ST-segment elevation myocardial infarction (STEMI) as a predictor of outcome. The 10-year risk of ASCVD was calculated for each patient using the Pooled Cohort Equations with a cutoff for increased level of ASCVD risk of 10%. Potential confounders were analyzed using inverse probability of treatment weighting on the basis of propensity scores.

Results:

A total of 1,824 (12.6%) patients reported prior use of statins. Statin users were more often former smokers, had higher body mass index, and more frequently had diabetes, hypertension, hypercholesterolemia, chronic kidney disease, prescribed concomitant evidence-based medications (aspirin, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and beta-blockers), and had a higher predicted 10-year ASCVD risk compared to nonstatin users. After adjustment for inverse probability of treatment weighting, no statistically significant or clinically relevant standardized differences were observed between statin users and nonusers.

Previous statin use was associated with significantly decreased prevalence of AHF at the time of ACS admission (absolute difference 4.3%; relative risk [RR], 0.72; 95% confidence interval [CI], 0.62-0.83). The effect of statins was consistent despite age (interaction p = 0.27) and gender (interaction p = 0.22). Notably, statin benefits were observed in patients with higher ASCVD risk (RR, 0.73; 95% CI, 0.63-0.85), but the same benefit was not seen in the lower-risk group (RR, 0.85; 95% CI, 0.6-1.2). Statin use was associated with a more pronounced decreased risk of presenting with AHF for those with diabetes or current smokers compared to their counterparts (interaction p = 0.03). A lower risk of 30-day mortality was observed for statin users (15.5%) compared with statin nonusers (20.7%; RR, 0.71; 95% CI, 0.5-0.99), but only for patients presenting with AHF on hospital admission. Prior statin use was associated with a lower risk of STEMI presentation and patients presenting with STEMI were more likely to have AHF on hospital admission for ACS.

Conclusions:

Treatment with statins reduces the risk of AHF events and early mortality from AHF events in adults presenting with ACS as the first manifestation of CVD.

Perspective:

This retrospective study supports the US Preventive Services Task Force (USPSTF) recommendation to prescribe statin therapy for the primary prevention of CVD for adults aged 40-75 years, with ≥1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking), and an estimated 10-year risk of a CV event of ≥10%. Important limitations included that the study population was entirely Caucasian, lack of data regarding type or intensity of statin therapy, and that ASCVD risk was calculated at the time of the index event (not at the time of statin initiation).

Clinical Topics: Acute Coronary Syndromes, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Homozygous Familial Hypercholesterolemia, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Hypertension, Chronic Angina

Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Angiotensin-Converting Enzyme Inhibitors, Atherosclerosis, Aspirin, Body Mass Index, Diabetes Mellitus, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hypertension, Myocardial Infarction, Patient Care Team, Primary Prevention, Renal Insufficiency, Chronic, Risk Factors, Smokers, ST Elevation Myocardial Infarction


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