More evidence is available supporting the preemptive use of statins
in patients undergoing cardiac surgery, only this time the benefit
extends to patients without existing coronary artery disease [1].

A new retrospective review, published in the December 2008 issue of
the Journal of Thoracic and Cardiovascular Surgery, has shown that
the preoperative use of statins is associated with lower mortality
among patients undergoing valve surgery.

"Clinically, this study implies that a preemptive use of
preoperative statins may improve operative outcomes in patients
undergoing cardiac valve surgery who do not have a history of
coronary artery disease," write lead investigator Dr Minoru Tabata
(Brigham and Women's Hospital, Boston, MA) and colleagues. "Our
cohort includes concomitant aortic, congenital, and other cardiac
procedures. Combined with previous findings in coronary artery
bypass graft and patients with coronary artery disease, the
beneficial effects of preoperative statins may be generalizable to
most patients undergoing cardiac surgery."

Patients Without a History of Coronary Artery Disease

The use of preoperative statin therapy among patients undergoing
CABG surgery has been shown to improve operative outcomes in other
studies, including a large 30 000-patient meta-analysis published in
the June 2008 issue of the European Heart Journal [2]. In that
study, previously reported by heartwire, preoperative statins
reduced the risk of 30-day mortality from any cause by 40%, as well
as significantly reduced the risk of stroke and atrial fibrillation.

As Tabata and colleagues point out, however, the role for
preoperative statins in patients without coronary artery disease is
less defined.

In this review, the investigators analyzed data from 1389 patients
undergoing cardiac valve surgery, excluding those undergoing
concomitant CABG surgery and those with a history of MI. Of these
patients, 363 were treated with a statin, including 197 who were
taking atorvastatin and 126 who were taking simvastatin. More than
half of the atorvastatin patients were taking the 10-mg dose,
whereas most simvastatin patients were taking either the 20-mg or 40-
mg dose.

Patients pretreated with statins prior to surgery had a lower rate
of operative mortality--defined as death within 30 days after
surgery--than those not taking statins. The rate of death was 0.8%
among the statin-treated patients compared with 2.3% for the non¡V
statin-treated group, a difference that translated into a 75% lower
risk of death within 30 days. Statin pretreatment had no effect on
the risk of stroke or perioperative MI rates.

The pleiotropic effects of statins, including improved endothelial
function, enhanced stability of atherosclerotic plaque, decreased
oxidative stress and inflammation, and an inhibited thrombogenic
response are possible biological mechanisms underlying the
beneficial effect, suggest the authors.

"These effects may attenuate the proinflammatory effects of surgical
invasiveness and cardiopulmonary bypass," write Tabata and
colleagues. Further study, however, is needed to confirm the
benefit, as well as to confirm the biological mechanism providing
the reduction in mortality, they add.

Statin Pretreatment Reduces Myocardial Damage

Another study, also appearing in the December 2008 issue of the
Journal of Thoracic and Cardiovascular Surgery, has shown that
pretreatment with statins, specifically rosuvastatin (Crestor,
AstraZeneca), reduces myocardial damage following cardiac surgery
[3].

In total, 200 patients, including those with coronary artery
disease, were randomized to rosuvastatin 20 mg or placebo one week
before coronary surgery. Troponin I, myoglobin, and creatine kinase-
MB mass levels--all markers of myocardial injury--were lower after
surgery among patients pretreated with rosuvastatin. High-
sensitivity C-reactive protein (hs-CRP) levels were also
significantly less elevated; CRP increased 58% in the pretreated
statin-therapy arm and 88% in those randomized to placebo.

In their paper, lead investigator Dr Vito Mannacio (University of
Naples Federico II, Italy) and colleagues point out that large event-
driven studies are needed to assess the advantages of preoperative
statin therapy and that other populations, including those with
diabetes, unstable patients, and patients with extensive coronary
artery disease and decreased left ventricular function, need to be
included in future trials.


Tabata M, Khalpey Z, Cohn LH, et al. Effect of preoperative statins
in patients without coronary artery disease who undergo cardiac
surgery. J Thorac Cardiovasc Surg 2008: 136: 1510-1513. Abstract
Liakopoulos OJ, Choi YH, Haldenwang PL, et al. Impact of
preoperative statin therapy on adverse postoperative outcomes in
patients undergoing cardiac surgery: a meta-analysis of over 30 000
patients. Eur Heart Journal 2008; 29:1548-1559. Abstract
Mannacio V, Iorio D, De Amicis V, et al. Effect of rosuvastatin
pretreatment on myocardial damage after coronary surgery. J Thorac
Cardiovasc Surg 2008: 136:1541-1548. Abstract