Statin Therapy-Evidence Beyond Lipid Lowering Contributing to Plaque Stability

Effects of atorvastatin and rosuvastatin on dysfunctional coronary circulation in patients with ST-segment elevation myocardial infarction

OBJECTIVE

Evidence of therapy for dysfunctional coronary circulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) is limited. This study was performed to compare the effects of atorvastatin and rosuvastatin on dysfunctional coronary circulation.

METHODS

This retrospective study enrolled 597 consecutive patients with STEMI who underwent pPCI in 3 centers from June 2016 to December 2019. Dysfunctional coronary circulation was defined by the thrombolysis in myocardial infarction (TIMI) grade and the TIMI myocardial perfusion grade (TMPG). Logistic regression analysis was used to evaluate the impact of different statin types on dysfunctional coronary circulation.

RESULTS

The incidence of TIMI no/slow reflow did not differ between the two groups, but the incidence of TMPG no/slow reflow was significantly lower in the atorvastatin than rosuvastatin group (44.58% vs. 57.69%, respectively). After multivariate adjustment, the odds ratio with 95% confidence interval of rosuvastatin was 1.72 (1.17-2.52) for after pretreatment TMPG no/slow reflow and 1.73 (1.16-2.58) for after stenting TMPG no/slow reflow. Atorvastatin and rosuvastatin showed no significant differences in clinical outcomes during hospitalization.

CONCLUSIONS

Compared with rosuvastatin, atorvastatin was associated with better coronary microcirculatory perfusion in patients with STEMI who underwent pPCI.

Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study

Background

Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis.

Methods

Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose.

Results

The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919).

Conclusions

Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02104-z.

Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting

BACKGROUND AND PURPOSE

We investigated whether statin pretreatment can dose dependently reduce periprocedural complications in patients undergoing carotid artery stenting because of symptomatic carotid artery stenosis.

METHODS

We enrolled a consecutive series of 397 symptomatic carotid artery stenosis (≥50% stenosis on conventional angiography) treated with carotid artery stenting at 2 tertiary university hospitals over a decade. Definition of periprocedural complications included any stroke, myocardial infarction, and death within 1 month after or during the procedure. Statin pretreatment was divided into 3 categories according to the atorvastatin equivalent dose: none (n=158; 39.8%), standard dose (<40 mg of atorvastatin, n=155; 39.0%), and high dose (≥40 mg; n=84; 21.2%). A multivariable logistic regression analysis with the generalized estimating equation method was used to investigate independent factors in periprocedural complications.

RESULTS

The patients' mean age was 68.7 years (81.6% men). The periprocedural complication rates across the 3 categories of statin use were 12.0%, 4.5%, and 1.2%. After adjustment, a change in the atorvastatin dose category was associated with reduction in the odds of periprocedural complications for each change in dose category (standard-dose statin: odds ratio, 0.24; 95% confidence interval, 0.07-0.81; high-dose statin: odds ratio, 0.11; 95% confidence interval, 0.01-0.96; P for trend=0.01). Administration of antiplatelet drugs was also an independent factor in periprocedural complications (OR, 0.18; 95% CI, 0.05-0.69).

CONCLUSIONS

This study shows that statin pretreatment may reduce the incidence of periprocedural complications dose dependently in patients with symptomatic carotid artery stenting.

Efficacy of HMG-CoA reductase inhibitors in the prevention of cerebrovascular attack in 1016 patients older than 75 years among 4014 type 2 diabetic individuals

BACKGROUND/OBJECTIVES

HMG-CoA reductase inhibitors (statins) reduce ischemic heart disease (IHD) in middle-aged diabetic individuals, and LDL-cholesterol (LDL-C) is a risk factor. However, their preventive effects on cerebrovascular attack (CVA) have not been identified in elderly, especially in elderly ≥ 75 years (late elderly), who account for approximately 30% of diabetic individuals in Japan. Randomized controlled studies of statins for late elderly are difficult to carry out, because many co-morbidities in elderly disrupt randomized controlled conditions.

METHODS

We performed a prospective cohort study (Japan Cholesterol and Diabetes Mellitus Study) with 5.5 years of follow-up since 2004. A total of 4014 type 2 diabetic patients without previous IHD or CVA (n=1936 women; age = 67.4 ± 9.5 years; ≥ 75 years: n = 1016) were enrolled, while 405 patients were registered as sub-cohort patients. We recorded detailed information on medications and laboratory data after every change in medication in patients of sub-cohort and suffered from IHD or CVA. We subdivided statin-users into prevalent, new and non-users.

RESULTS

A total of 104 CVAs occurred during 5.5-years. Plasma HDL-C level was inversely correlated with CVA in patients ≥ 65 years. In case-control study, among patients who were not prescribed statins, CVA increased in age-dependent manner. CVA incidence was lower in prevalent and new statin-users than in non-users (hazard ratio [HR]:0.46, 0.523), especially in late elderly (HR: 0.51, 0.21). Statins reduced CVAs mainly due to a direct effect and partially due to the effects of HDL-C and glucose metabolism. No significant differences were observed between statins.

CONCLUSION

Statins prevented CVA in middle-aged, elderly and late elderly diabetic patients via a direct effect. This study is the first to demonstrate the usefulness of observational studies for statistically analyzing agents' effects on late elderly.

Statins reduce peri-procedural complications in carotid stenting

BACKGROUND

In primary and secondary prevention, statins significantly reduce cardiovascular and cerebrovascular events. Pre-interventional statin medication shows a benefit in carotid artery stenosis patients treated with endarterectomy; however, there are few data available for patients treated with stent-angioplasty. The aim of this study was to investigate whether pre-interventional statin therapy is associated with decreased peri-interventional risk of stroke, myocardial infarction, and mortality in patients undergoing stent-angioplasty for internal carotid stenosis.

METHODS

Data for 344 consecutively documented patients with internal carotid artery stenosis treated with stent-angioplasty in the years 2002-2012 at the same stroke center were collected in a prospectively defined database. Risk factors, medication, and indication for therapy were documented. Univariate and multivariate analysis was performed to investigate independent reduction of peri-interventional stroke, myocardial infarction, or death by statin medication prior to stent-angioplasty.

RESULTS

The median age was 70 years (p25: 63, p75: 76), 75.5% of patients were male, and the median stenosis was 85% according to ECST criteria (p25: 80%, p75: 90%). 20.1% of patients had asymptomatic stenoses, and 60.2% had statin medication before stenting. As per multivariate analysis, pre-interventional statin medication was a predictor for significant peri-interventional risk reduction regarding primary endpoint ischemic stroke, myocardial infarction (MI), or death (odds ratio (OR) 0.31, p = .006). Statins also had a significant protective effect in secondary endpoint ischemic stroke, intracranial bleeding or death (OR 0.39, p = .014), and ischemic stroke or myocardial infarction (OR 0.20; p = .002).

CONCLUSIONS

This study shows that pre-interventional statin medication has a protective effect against peri-interventional stroke, MI, or death in patients with internal carotid artery stenosis treated with stent-angioplasty. Accordingly, statins could be considered as a standard pre-interventional medical therapy in carotid stenting.

Effect of statin pretreatment on myocardial perfusion in patients undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

To achieve sufficient myocardial perfusion in ST-segment elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (PPCI), many adjunctive therapies have been proposed. Previous trials have reported variances in myocardial perfusion improvement for statin pretreatment, which made it inconvincible to confirm the beneficial effects of statins. Therefore, we performed a systematic review and meta-analysis to determine whether statin pretreatment was effective in improving myocardial perfusion.

HYPOTHESIS

Statin pretreatment could improve myocardial perfusion in STEMI patients undergoing PPCI.

METHODS

We searched the PubMed, Web of Knowledge, and the Cochrane Library databases for studies evaluating the impact of statin pretreatment on myocardial perfusion in STEMI patients receiving PPCI.

RESULTS

Twelve trials were finally included in our meta-analysis. There were no significant differences in patients' baseline characteristics between the statin pretreatment and control groups. Overall pooled analysis showed that patients in the statin pretreatment groups had significantly better epicardial coronary blood flow (measured by Thrombosis in Myocardial Infarction [TIMI] grade, odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.28 to 0.84; measured by corrected TIMI frame count, mean difference: -5.63; 95% CI: -9.66 to -1.6). A trend toward myocardial tissue level perfusion improvement was seen in the statin pretreatment arm rather than the control arm (measured by myocardial blush grade, OR: 0.74; 95% CI: 0.50 to 1.09).

CONCLUSIONS

This present meta-analysis suggests that statin pretreatment might be effective in improving myocardial perfusion in STEMI patients.

GRADE guidelines: 8. Rating the quality of evidence--indirectness

Direct evidence comes from research that directly compares the interventions in which we are interested when applied to the populations in which we are interested and measures outcomes important to patients. Evidence can be indirect in one of four ways. First, patients may differ from those of interest (the term applicability is often used for this form of indirectness). Secondly, the intervention tested may differ from the intervention of interest. Decisions regarding indirectness of patients and interventions depend on an understanding of whether biological or social factors are sufficiently different that one might expect substantial differences in the magnitude of effect. Thirdly, outcomes may differ from those of primary interest-for instance, surrogate outcomes that are not themselves important, but measured in the presumption that changes in the surrogate reflect changes in an outcome important to patients. A fourth type of indirectness, conceptually different from the first three, occurs when clinicians must choose between interventions that have not been tested in head-to-head comparisons. Making comparisons between treatments under these circumstances requires specific statistical methods and will be rated down in quality one or two levels depending on the extent of differences between the patient populations, co-interventions, measurements of the outcome, and the methods of the trials of the candidate interventions.

Basic Science Review Section: Statin Therapy—Part II: Clinical Considerations for Cardiovascular Disease

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, commonly known as statins, are the medical treatment of choice for hypercholesterolemia. In addition to achieving a therapeutic decrease in serum cholesterol levels, statin therapy appears to promote pleiotropic effects that are independent of changes in serum cholesterol. These cholesterol lowering and pleiotropic effects are beneficial not only for the coronary circulation, but for the myocardium and peripheral arterial system as well. Patients receiving statin therapy must be carefully monitored, however, as statins potentially have harmful side effects and drug interactions. This article is part II of a 2-part review, and it focuses on the clinical aspects of statin therapy in cardiovascular disease.

Prevention of atherosclerosis in patients living with HIV

INVESTIGATIONAL PRODUCT: Rosuvastatin (Crestor; Astra Zeneca).

ACTIVE INGREDIENTS

Rosuvastatin (5 mg).

STUDY TITLE

Prevention of Atherosclerosis in Patients Living with HIV.

PHASE OF STUDY

Phase III.

AIMS

PRIMARY AIM: To assess whether rosuvastatin therapy could slow the progression of the carotid intima-media thickness (C-IMT; as measured by the change in the mean IMT of the near and far walls of the distal common carotid arteries) over 2 years in HIV-infected patients (HIV-IP).

SECONDARY AIMS

To assess whether rosuvastatin therapy could reduce highly sensitive C reactive protein (hs-CRP) inflammatory marker that is increased in HIV-IP.To assess the effect of rosuvastatin therapy on serum lipid levels (total cholesterol [TC], low-density lipoprotein [LDL] cholesterol, high-density lipoprotein [HDL] cholesterol and triglycerides [TG]) and apolipoproteins (APO A1, APO B and APO B/A1).To assess the safety of rosuvastatin in HIV-IP through the evaluation of clinical laboratory analyses (liver function tests and creatine kinase) and adverse events (AEs).

STUDY DESIGN

Two-year randomized, double-blind, placebo-controlled, parallel group study.

PLANNED SAMPLE SIZE

320 HIV-IP.

SUMMARY OF ELIGIBILITY CRITERIA

HIV-IP who are aged between 30 and 60 years, with a CD4 count. greater than 200 cells/mm(3). Patients must be stable on combination antiretroviral therapy (cART) for at least 12 months and have a 10-year CVD risk of less than 20% (using the Framingham risk score).

NUMBER OF STUDY CENTERS

One.

DURATION OF TREATMENT

Two years (5 mg rosuvastatin or placebo once daily).

DOSE AND ROUTE OF ADMINISTRATION

Oral rosuvastatin (5 mg) once daily. The incidence of cardiovascular disease (CVD) in HIV-IP is at least three times higher than in the general population and further increases each year with combination anti-retroviral therapy (cART). The carotid atherosclerosis progression rate is 10 times higher in HIV-IP than in uninfected individuals. The aim of this study is to assess whether therapy with 5 mg rosuvastatin could: 1) Slow the progression in the mean IMT of the distal common carotid arteries over two years in HIV-IP.2) Change the concentration in the inflammatory marker--hs-CRP, which is increased in HIV-IP.3) Change the concentrations of TC, LDL cholesterol, HDL cholesterol, TG, apolipoproteins (APO) B, APO A1 and APO B/A1.4) Be administered safely in the study population. Pharmacological intervention with rosuvastatin will be evaluated in a double-blind, placebo-controlled, randomized clinical trial in HIV-IP treated with cART not matching the published selection criteria for lipid-lowering therapy. For the first time, this study will investigate anti-inflammatory and anti-atherogenic effects of a pharmacological lipid-lowering agent in HIV-IP that may lead to the reduction of CVD.

Effect of previous treatment with statins on outcome of patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Beyond lipid-lowering effects, statins have favorable effects on platelets, endothelial function, plaque stability, and inflammation. These "pleiotropic" effects could contribute to microvascular function preservation during ischemia. Data are limited about the impact of previous treatment with statins on outcomes of patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Accordingly, the aim was to evaluate the effect of previous statin treatment on clinical outcomes of such patients. A total of 950 consecutive patients with STEMI treated with primary PCI who were included in our primary PCI registry from January 2001 to July 2007 were studied. Excluded were patients with cardiogenic shock. Patients were allocated into 2 groups: those who received previous statin treatment (n=327) and those who did not (n=623). Patients who received previous statin treatment were older and more likely to be women; have diabetes, hypertension, hyperlipidemia, renal insufficiency, and anemia; or have had a previous myocardial infarction. Procedural characteristics were similar between the 2 groups. Despite the higher risk profile, patients who received previous statin treatment had a lower 30-day mortality rate (1.5% vs 3.8%; p=0.05). However, at 6 months, mortality differences were no longer evident and patients who received previous statin therapy had a higher rate of target-vessel revascularization (12.4% vs 7.6%; p=0.02). Multivariate analysis showed that previous statin treatment was associated with an odds ratio of 0.4 (95% confidence interval 0.13 to 0.96, p=0.045) for 30-day mortality. In conclusion, the present study suggested that previous therapy with statins in patients with STEMI treated using primary PCI may be associated with reduced short-term mortality.

In-Stent Restenosis of the Renal Artery in a Single Kidney Patient: The Role of ACEI in the Therapeutic Choice

Renal artery stenosis (RAS) caused by atherosclerotic changes of the renal arteries has become a concern as a cause of end-stage renal failure. Percutaneous balloon angioplasty with or without endovascular stenting is an increasingly accepted procedure at the expense of classical approaches such as aortorenal bypass and other types of surgery. Renal percutaneous transluminal angioplasty and stenting (RPTAS) represent the first therapeutic choice; however, there is doubt regarding the satisfactory long-term outcome for primary RPTAS. Currently, there is no clear evidence whether or not RPTAS prevents further progressive renal function decline because comparisons between interventional randomized studies and medical therapy are still lacking. Despite the fact that the use of angiotensin-converting enzyme inhibitors (ACEIs) may be a potential cause of acute renal failure, clinical data suggest that ACEI therapy is associated with better survival in patient with RAS. In our case, the use of ACEIs has been fundamental for the indirect evaluation of restenosis degree and RPTAS.

Role of HMG-CoA reductase inhibitors in neurological disorders : progress to date

Inhibitors of HMG-CoA reductase (statins) are cholesterol-lowering agents that dramatically reduce morbidity and mortality in patients with established cardiovascular disease. In addition, they exhibit pleiotropic effects that operate independently of lipid modification. Statin administration results in greater nitric oxide bioavailability, improved endothelial function, enhanced cerebral blood flow, immune modulation with anti-inflammatory action, decreased platelet aggregation and antioxidant activity. Some or all of these effects may improve outcome or ameliorate symptoms in neurological disorders. This article examines the potential role of statins in treating stroke, Alzheimer's disease, multiple sclerosis and Parkinson's disease. Studies are ongoing in this controversial area, but there are no firm conclusions. The appropriateness of initiating statin therapy for neurological disorders is not established at this time. The exception is stroke, in which recurrence is significantly reduced by statin therapy.

Carbonylation of epoxides to substituted 3-hydroxy-delta-lactones

Substituted 3-hydroxy-delta-lactones (3HLs) are valuable intermediates in the synthesis of pharmaceuticals and other biologically active natural products. Herein we report the first example of the catalytic carbonylation of substituted homoglycidols to 3HLs using HCo(CO)4. Upon optimization of the catalyst and reaction conditions, a functionally diverse set of 3HLs was prepared. Mechanistic insight was gained by observation of the carbonylation reaction using in situ IR spectroscopy, and we propose a mechanism that is consistent with previously studied epoxide carbonylation systems.