Statin use and survival in patients with chronic heart failure — results from two observational studies with 5200 patients

Statin therapy impact on Long-Term outcomes in acute heart Failure: Retrospective analysis of hospitalized patients

Background

Statin therapy is well-established for treating hyperlipidemia and ischemic heart disease (IHD), but its role in Acute Decompensated Heart Failure (ADHF) remains less clear. Despite varying clinical guidelines, the actual utilization and impact of statin therapy initiation in patients with ADHF with an independent indication for statin therapy have not been thoroughly explored.

Methods

We conducted a retrospective observational study on 5978 patients admitted with ADHF between January 1st, 2007, and December 31st, 2017. Patients were grouped based on their statin therapy status at admission and discharge. We performed multivariable analyses to identify independent predictors of short-term, intermediate-term, and long-term mortality. A sensitivity analysis was also conducted on patients with an independent indication for statin therapy but who were not on statins at admission.

Results

Of the total patient cohort, 73.9% had an indication for statin therapy. However, only 38.2% were treated with statins at admission, and 56.1% were discharged with a statin prescription. Patients discharged with statins were younger, predominantly male, and had a higher prevalence of IHD and other comorbidities. Statin therapy at discharge was an independent negative predictor of 5-year all-cause mortality (hazard ratio 0.80, 95% confidence interval 0.76-0.85). The sensitivity analysis confirmed these findings, demonstrating higher mortality rates in patients not initiated on statins during admission.

Conclusions

The study highlights significant underutilization of statin therapy among patients admitted with ADHF, even when there's an independent indication for such treatment. Importantly, initiation of statin therapy during hospital admission was independently associated with improved long-term survival.

Impact of Statin Therapy in Heart Failure Patients: Results of a Large Real-World Experience

Background

The use of statins in patients with heart failure (HF) is controversial. In patients without HF, statins reduce atherosclerotic cardiovascular disease (ASCVD) risk, including HF-related events. However, in some large studies, no benefit was seen in statin-treated HF patients.

Objectives

The purpose of this study was to determine the impact of statin therapy in HF with reduced ejection fraction (HFrEF).

Methods

Intermountain Healthcare medical records identified patients with a HF diagnosis and an ejection fraction of ≤40%. Patients prescribed and not prescribed a statin were compared for major adverse cardiovascular events (MACE) (death, myocardial infarction, stroke) (median of 4.5 years follow-up). Statin use was defined as use at or after a HF diagnosis but at least 60 days before MACE or end of follow-up. Cox proportional hazards regression was used to determine the relationship between statin use and outcomes.

Results

A total of 15,010 patients (n = 9,641 [64%] on statins) were studied. Statin use was associated with more frequent ASCVD risk factors yet a lower risk of MACE risk (adjusted HR: 0.53; 95% CI: 0.51-0.56; P < 0.0001). Benefit was similar for primary and secondary prevention patients and for prior and new statin prescriptions. Using time-varying hazard ratio analysis, the longer the patient was on a statin, the greater the reduction in risk of MACE (P < 0.0001).

Conclusions

These results suggest a potential benefit of selective statin use in the real-world management of HFrEF patients with ASCVD or at high ASCVD risk.

Reduced Heart Failure and Mortality in Patients Receiving Statin Therapy Before Initial Acute Coronary Syndrome

BACKGROUND

There is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF).

OBJECTIVES

The aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD.

METHODS

Data were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF.

RESULTS

Previous statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99).

CONCLUSIONS

Among adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173).

Determinants of the survival benefit associated with statins in patients with acute heart failure

Aims

The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated the determinants of the survival benefit associated with statins in HF patients.

Methods and results

We enrolled 1680 acute HF patients receiving statins and 2157 patients not receiving statins admitted between 2009 and 2016. The left ventricular (LV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. The primary outcome was 5 year all‐cause mortality. Statin therapy was independently associated with improved survival in patients with HF with preserved ejection fraction (HFpEF) [adjusted hazard ratio (HR) 0.781, 95% confidence interval (CI) 0.621–0.981, P = 0.034], but not in those with HF with reduced EF (HFrEF) (adjusted HR 0.881, 95% CI 0.712–1.090, P = 0.244). Mortality reduction associated with statin therapy was significant in patients with ischaemic HF (adjusted HR 0.775, 95% CI 0.607–0.989, P = 0.040), but not in those with non‐ischaemic HF (adjusted HR 0.895, 95% CI 0.734–1.092, P = 0.275). The relative magnitude of survival benefit with statin therapy increased as LV‐EF and LV‐GLS increased, with a steeper dose–response relationship in patients with ischaemic HF. In the subgroup of patients with ischaemic HF, survival benefit with statin therapy was confined to those ≤75 years of age.

Conclusions

Our study suggests that the survival benefit of statins is confined to patients with HFpEF and those with ischaemic HF. Myocardial contractility may modulate the prognostic effects of statins in HF patients, particularly when the aetiology is ischaemic rather than non‐ischaemic.

Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis

BACKGROUND

The role of statins in patients with heart failure (HF) of different levels of left ventricular ejection fraction (LVEF) remains unclear especially in the light of the absence of prospective data from randomized controlled trials (RCTs) in non-ischemic HF, and taking into account potential statins' prosarcopenic effects. We assessed the association of statin use with clinical outcomes in patients with HF.

METHODS

We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until August 2018 for RCTs and prospective cohorts comparing clinical outcomes with statin vs non-statin use in patients with HF at different LVEF levels. We followed the guidelines of the 2009 PRISMA statement for reporting and applied independent extraction by multiple observers. Meta-analyses of hazard ratios (HRs) of effects of statins on clinical outcomes used generic inverse variance method and random model effects. Clinical outcomes were all-cause mortality, cardiovascular (CV) mortality and CV hospitalization.

RESULTS

Finally we included 17 studies (n = 88,100; 2 RCTs and 15 cohorts) comparing statin vs non-statin users (mean follow-up 36 months). Compared with non-statin use, statin use was associated with lower risk of all-cause mortality (HR 0.77, 95% confidence interval [CI], 0.72-0.83, P < 0.0001, I2 = 63%), CV mortality (HR 0.82, 95% CI: 0.76-0.88, P < 0.0001, I2 = 63%), and CV hospitalization (HR 0.78, 95% CI: 0.69-0.89, P = 0.0003, I2 = 36%). All-cause mortality was reduced on statin therapy in HF with both EF < 40% and ≥ 40% (HR: 0.77, 95% Cl: 0.68-0.86, P < 0.00001, and HR 0.75, 95% CI: 0.69-0.82, P < 0.00001, respectively). Similarly, CV mortality (HR 0.86, 95% CI: 0.79-0.93, P = 0.0003, and HR 0.83, 95% CI: 0.77-0.90, P < 0.00001, respectively), and CV hospitalizations (HR 0.80 95% CI: 0.64-0.99, P = 0.04 and HR 0.76 95% CI: 0.61-0.93, P = 0.009, respectively) were reduced in these EF subgroups. Significant effects on all clinical outcomes were also found in cohort studies' analyses; the effect was also larger and significant for lipophilic than hydrophilic statins.

CONCLUSIONS

In conclusion, statins may have a beneficial effect on CV outcomes irrespective of HF etiology and LVEF level. Lipophilic statins seem to be much more favorable for patients with heart failure.

Association is not causation: treatment effects cannot be estimated from observational data in heart failure

Aims

Treatment 'effects' are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF).

Methods and results

We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the 'effect' of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect.

Conclusion

This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients.

Impact of statin therapy on all-cause mortality and ICD interventions in heart failure patients - a systematic review

OBJECTIVES

Implantable cardioverter defibrillators (ICDs) have a unique role for the primary and secondary prevention of sudden cardiac death (SCD). The aim of our systematic review is to present the existing data about the impact of statins on all-cause mortality and ICD interventions in heart failure (HF) patients who had an ICD implanted either for primary or for secondary prevention of SCD.

METHODS AND RESULTS

We searched PubMed database and the reference list of the relevant studies for retrieving studies evaluating the effect of statins on all-cause mortality and ICD interventions in HF patients. We finally included 17 relevant studies in our systematic review. Of them, nine studies included data about the impact of statins on all-cause mortality, eight studies about the impact of statins on appropriate ICD interventions and three studies about the impact of statins on inappropriate ICD interventions in HF patients. These data showed that statins seem to have a beneficial role in the reduction of all-cause mortality and ICD interventions in HF patients.

CONCLUSIONS

Statins seem to have a beneficial role in the reduction of all-cause mortality and ICD interventions in HF patients. However, further research about pleiotropic effects of statins is needed as well randomized control trials to elucidate the exact role of statin therapy in ICD outcomes.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. 
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Discontinuation of Statins: What Are the Risks?

The key benefits of statin therapy have been well established in both primary and secondary prevention cardiovascular patients. Many studies have shown a significant statin discontinuation rate within the first year of initiation whether for primary or secondary prevention. National guidelines for the management of dyslipidemia highlight the lack of benefit seen with statin therapy in patients with chronic kidney disease receiving dialysis, heart failure with reduced ejection fraction, and patients greater than 75 years of age without atherosclerotic cardiovascular disease. Available data outside of these patient populations do not support discontinuation of statin therapy. Recent studies support an association with statin discontinuation and increased risk of myocardial infarction and cardiovascular death. Based on the available data, discontinuation of statin therapy should be carefully considered.

Statin Treatment and Clinical Outcomes of Heart Failure Among Africans: An Inverse Probability Treatment Weighted Analysis

Background

Randomized control trials of statins have not demonstrated significant benefits in outcomes of heart failure (HF). However, randomized control trials may not always be generalizable. The aim was to determine whether statin and statin type–lipophilic or –hydrophilic improve long‐term outcomes in Africans with HF.

Methods and Results

This was a retrospective longitudinal study of HF patients aged ≥18 years hospitalized at a tertiary healthcare center between January 1, 2009 and December 31, 2013 in Ghana. Patients were eligible if they were discharged from first admission for HF (index admission) and followed up to time of all‐cause, cardiovascular, and HF mortality or end of study. Multivariable time‐dependent Cox model and inverse‐probability‐of‐treatment weighting of marginal structural model were used to estimate associations between statin treatment and outcomes. Adjusted hazard ratios were also estimated for lipophilic and hydrophilic statin compared with no statin use. The study included 1488 patients (mean age 60.3±14.2 years) with 9306 person‐years of observation. Using the time‐dependent Cox model, the 5‐year adjusted hazard ratios with 95% CI for statin treatment on all‐cause, cardiovascular, and HF mortality were 0.68 (0.55–0.83), 0.67 (0.54–0.82), and 0.63 (0.51–0.79), respectively. Use of inverse‐probability‐of‐treatment weighting resulted in estimates of 0.79 (0.65–0.96), 0.77 (0.63–0.96), and 0.77 (0.61–0.95) for statin treatment on all‐cause, cardiovascular, and HF mortality, respectively, compared with no statin use.

Conclusions

Among Africans with HF, statin treatment was associated with significant reduction in mortality.

Statins attenuate but do not eliminate the reverse epidemiology of total serum cholesterol in patients with non-ischemic chronic heart failure

BACKGROUND

In patients with chronic heart failure (CHF) increasing levels of total serum cholesterol are associated with improved survival - while statin usage is not. The impact of statin treatment on the "reverse epidemiology" of cholesterol is unclear.

METHODS

2992 consecutive patients with non-ischemic CHF due to left ventricular systolic dysfunction from the Norwegian CHF Registry and the CHF Registries of the Universities of Hull, UK, and Heidelberg, Germany, were studied. 1736 patients were individually double-matched on both cholesterol levels and the individual propensity scores for statin treatment. All-cause mortality was analyzed as a function of baseline cholesterol and statin use in both the general and the matched sample.

RESULTS

1209 patients (40.4%) received a statin. During a follow-up of 13,740 patient-years, 360 statin users (29.8%) and 573 (32.1%) statin non-users died. When grouped according to total cholesterol levels as low (≤3.6mmol/L), moderate (3.7-4.9mmol/L), high (4.8-6.2mmol/L), and very high (>6.2mmol/L), we found improved survival with very high as compared with low cholesterol levels. This association was present in statin users and non-users in both the general and matched sample (p<0.05 for each group comparison). The negative association of total cholesterol and mortality persisted when cholesterol was treated as a continuous variable (HR 0.83, 95%CI 0.77-0.90, p<0.001 for matched patients), but it was less pronounced in statin users than in non-users (F-test p<0.001).

CONCLUSIONS

Statins attenuate but do not eliminate the reverse epidemiological association between increasing total serum cholesterol and improved survival in patients with non-ischemic CHF.

Lipophilic Statin Versus Rosuvastatin (Hydrophilic) Treatment for Heart Failure: a Meta-Analysis and Adjusted Indirect Comparison of Randomised Trials

OBJECTIVES

This study aims to compare lipophilic and hydrophilic statin therapy on clinical outcomes of heart failure (HF) using a systematic review and an adjusted indirect comparison meta-analysis. Outcomes were all-cause mortality, cardiovascular mortality, cardiovascular hospitalization and hospitalization for worsening HF.

METHODS

We conducted a search of PubMed, EMBASE and Cochrane databases until 31st December 2014 for randomized control trials (RCTs) in HF evaluating statins versus placebo. Identified RCTs and their respective abstracted information were grouped according to statin type evaluated and analyzed separately. Outcomes were initially pooled with the Peto's one-step method, producing odd ratios (OR) and 95 % confidence intervals (CI) for each statin type. Using these pooled estimates, we performed adjusted indirect comparisons of lipophilic versus hydrophilic statin for each outcome.

RESULTS

Thirteen studies involving 10,966 patients were identified and analyzed. Lipophilic statins were superior to hydrophilic rosuvastatin regarding all-cause mortality (OR 0 · 50; 95 % CI, 0 · 11-0 · 89; p = 0 · 01), cardiovascular mortality (OR 0 · 61; 0 · 25-0 · 97; p = 0 · 009), and hospitalization for worsening HF (OR 0 · 52; 0 · 21-0 · 83; p = 0 · 0005). However, both statins were comparable with regards to cardiovascular hospitalization [OR 0 · 80 (0 · 31, 1 · 28); p = 0 · 36].

CONCLUSIONS

Lipophilic statin treatment shows significant decreases in all-cause mortality, cardiovascular mortality and hospitalization for worsening HF compared with rosuvastatin treatment. This meta-analysis provides preliminary evidence that lipophilic statins offer better clinical outcomes in HF till data from head to head comparisons are available.

Review of novel therapeutic targets for improving heart failure treatment based on experimental and clinical studies

Heart failure (HF) is a major public health priority due to its epidemiological transition and the world's aging population. HF is typified by continuous loss of contractile function with reduced, normal, or preserved ejection fraction, elevated vascular resistance, fluid and autonomic imbalance, and ventricular dilatation. Despite considerable advances in the treatment of HF over the past few decades, mortality remains substantial. Pharmacological treatments including β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists have been proven to prolong the survival of patients with HF. However, there are still instances where patients remain symptomatic, despite optimal use of existing therapeutic agents. This understanding that patients with chronic HF progress into advanced stages despite receiving optimal treatment has increased the quest for alternatives, exploring the roles of additional pathways that contribute to the development and progression of HF. Several pharmacological targets associated with pathogenesis of HF have been identified and novel therapies have emerged. In this work, we review recent evidence from proposed mechanisms to the outcomes of experimental and clinical studies of the novel pharmacological agents that have emerged for the treatment of HF.

Effects of Statin Therapy on Clinical Outcomes of Survivors of Acute Myocardial Infarction with Severe Systolic Heart Failure

Objective

Large randomized trials have failed to show a beneficial effect of statin treatment in chronic HF. The investigators tried to evaluate the long-term effects of statin therapy in patients with new onset heart failure (HF) following acute myocardial infarction (AMI).

Methods

Between January 2008 and December 2011, a total of 13,616 AMI patients were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) which was a prospective, multi-center, nationwide, web-based database of AMI in Korea. From this database, we studied 1,055 patients with AMI who had newly developed severe acute HF [left ventricular ejection fraction ≤ 40%] and were discharged alive. The patients were divided into two groups, a statin group (n = 756) and a no-statin group (n = 299). We investigated the one-year major adverse cardiovascular events (MACEs), including all-cause mortality, MI, and any revascularization of each group. We then performed a propensity-score matched analysis.

Results

In the original cohort, one-year MACEs were similar between the two groups (16.5% vs. 14.7% in the statin or no-statin groups; p = 0.47). Propensity-score matching yielded 256 pairs, and in that population we observed comparable results in terms of MACEs (18.0% vs. 12.5% in the statin or no-statin groups, p = 0.11) and mortality (5.1% vs. 3.5% in the statin or no-statin groups, p = 0.51). Cox-regression analysis revealed that statin therapy was not an independent predictor for occurrence of a MACE [Hazard ratio (HR) 1.11, 95% CI 0.79–1.57, p = 0.54] or all-cause mortality (HR 1.42, 95% CI 0.75–2.70, p = 0.28).

Conclusion

Statin therapy was not associated with a reduction in the long-term occurrence of MACEs or mortality in survivors of AMI with severe acute HF in this retrospective cohort study.

What the guidelines do not say: statin non-benefit groups

The 2013 American College of Cardiology/American Heart Association guidelines for management of low-density lipoprotein cholesterol (LDL-C) to reduce atherosclerotic cardiovascular disease (ASCVD) risk identified four groups of adults (40-75 years of age) with significant evidence for benefit from statin therapy: presence of clinical ASCVD or diabetes, age ≥21 years and LDL-C >190 mg/dl, and 10-year risk of hard ASCVD events ≥7.5 % as determined by the new Cardiovascular Risk Calculator. However, clinicians are faced daily with at-risk patients who do not clearly match one of these statin-benefit groups. Understanding the limitations of available evidence and awareness of additional published guidelines for statin non-benefit groups will help practitioners make personalized decisions with patients and inform the clinician-patient discussion regarding potential risks and benefits of statin therapy.

Statin therapy improves long-term survival in non-ischaemic cardiomyopathy: a pooled analysis of 4500 patients

Statin therapy has demonstrated a beneficial effect in patients with chronic heart failure. While the majority of patients with ischaemic cardiomyopathy are prescribed these drugs, studies have demonstrated that less than one fifth of patients with dilated cardiomyopathy are on regular statin therapy. We have performed a meta-analysis of 4500 patients from six studies (four randomised controlled trials). Our results demonstrate that statin therapy significantly improves long-term survival in patients with non-ischaemic heart failure {Hazard ratio for mortality 0.45 (0.33-0.62); p<0.0001; I(2)=41%; p-value for heterogeneity=0.13}.

The role of statins in chronic heart failure

The efficacy of statins in reducing morbidity and mortality in patients with documented coronary artery disease is unquestionable. However, in chronic heart failure (CHF), evidence regarding the beneficial effects of statin therapy remains contradictory. Although numerous retrospective studies have demonstrated improved prognosis in CHF patients treated with statins, two randomized trials, GISSI-HF and CORONA, have not confirmed the benefit of rosuvastatin in this group of patients. The benefits of using statins in CHF probably result mostly from their pleiotropic action, including the improvement of endothelial function, the inhibition of neurohormonal activation, and the reduction of proinflammatory activation. On the other hand, it has been recognized that low cholesterol is associated with worse morbidity and mortality in patients with CHF. It appears that it is necessary to conduct further randomized clinical trials using different kinds of statins in different populations of patients with CHF.

Statin therapy in heart failure: for good, for bad, or indifferent?

Statins are effective in the prevention of coronary events and the treatment of acute coronary syndromes. However, their efficacy and safety in patients with heart failure (HF) is still a matter of debate. On the basis of literature evidence from subgroup analysis, retrospective, prospective cohort studies, and randomized controlled trials, in this review we try to answer the following question: Is statin therapy in HF patients for good, for bad, or indifferent? Some studies showed a negative impact of low cholesterol levels in patients with severe HF (endotoxin-lipoprotein hypothesis and coenzyme Q10 hypothesis). On the other hand, a large amount of literature demonstrates that in patients with HF, statins have a positive impact on survival and other outcomes, regardless of whether the HF was of ischemic or nonischemic origin, which is related to a combination of mechanisms (pleiotropic effects and cholesterol reduction). Much of this evidence, however, comes from observational and retrospective studies and subgroup analyses of statin use in patients with HF. Randomized clinical trials examining the efficacy of statins in HF (GISSI-HF and CORONA) did not show a benefit in mortality for patients with HF randomized to receive statins. Nevertheless, a meta-analysis found that statin therapy does not decrease all-cause or cardiovascular mortality but significantly decreases the rate of hospitalization for worsening HF and increased left ventricular ejection fraction compared with placebo.

Primary and secondary prevention of heart failure with statins

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.

Impact of aspirin and statins on long-term survival in patients hospitalized with acute myocardial infarction complicated by heart failure: an analysis of 1706 patients

AIMS

Aspirin and statins are established therapies for acute myocardial infarction (MI), but their benefits in patients with chronic heart failure (HF) remain elusive. We investigated the impact of aspirin and statins on long-term survival in patients hospitalized with acute MI complicated by HF.

METHODS AND RESULTS

Of 4251 patients in the Evaluation of Methods and Management of Acute Coronary Events (EMMACE)-1 and -2 observational studies, 1706 patients had HF. A propensity score-matching method estimated the average treatment effects (ATEs) of aspirin and statins on survival over 90 months. ATEs were calculated as relative risk differences in all-cause mortality comparing patients receiving aspirin and statins with controls, respectively. Moreover, combined aspirin and statins vs. none (ATE I), aspirin or statins vs. none (ATE II), and aspirin and statins vs. aspirin or statins (ATE III) were assessed. The median survival times of the ATE I, ATE II and ATE III were 25, 50, and 85 months, respectively. Regarding aspirin, the ATE was significantly improved at 6, 12, and 90 months [ATE 6 months: 10%, 95% confidence interval (CI) 3-18%], where the ATE of statins favoured survival at 1-24 months (ATE 1 month: 5%, 95% CI 0.3-10%). Mortality was lower at 1, 6, and 24 months in those who received aspirin and statins (ATE I). When the combination was compared with either treatment alone, an effect persisted between 6 and 90 months (ATE III).

CONCLUSION

In patients with acute MI complicated by HF, prescription of aspirin and statins either alone or together was associated with better long-term survival.

Evidence-based co-medication in heart failure: necessary or bystander?

This article refers to 'Impact of aspirin and statins on longterm survival in patients with acute myocardial infarction complicated by heart failure: an analysis in 1746 patients' by C. Lewinter et al., published in this issue on page 95-102.