Mixed data have been observed on the role of statins in the preventative setting of cardiovascular disease (CVD).¹ However, Dr. Raffaele Bugiardini, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Italy and his colleagues conducted a recent study published in the Journal of the American College of Cardiology, which demonstrated evidence that receiving statin therapy before initial acute coronary syndrome (ACS) could reduce acute heart failure (AHF) and improve patient survival rates.²

As the prevention of AHF and mortality is a major public health concern, statin therapy has been proved to be safe and significantly contributes to the reduction of atherosclerotic cardiovascular disease (ASCVD) in North America and Europe.^2-4 Also, statin therapy has been shown to be efficacious in reducing ASCVD in both men and women in a secondary preventative setting, but its efficacy for primary prevention is limited.^1,5

In this study, data were collected and analyzed from 14,542 patient archives from 2 clinical registries: the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) (41 centers in 12 countries, including Bosnia-Herzegovina, Croatia, Italy, Kosovo, Lithuania, Macedonia, Hungary, Moldova, Montenegro and Romania, Russia Federation and Serbia); and the EMMACE-3X (Long-term Follow-up of Health-Related Quality of Life in Patients with Acute Coronary-Syndrome) (47 hospitals in the United Kingdom).² Individuals diagnosed with ACS without a previous history of ASCVD events were included in the study, dated October 2010 to January 2019.²

The key outcome measure was the frequency of AHF on admission for ACS as the first incidence of ASCVD.² Analysis also covered the correlation of AHF with mortality occurred at 30 days from admission.² Additionally, to examine the complex association between AHF after ACS and mortality, the investigators identified ST-segment elevation myocardial infarction (STEMI) as a further indicator of outcome.²

Divided into 2 groups of statin users vs. statin non-users, patients were compared by using inverse probability weighting models.² Analysis centered on the interaction, if any, between statin therapy and the baseline characteristics.² The baseline characteristics were expressed as percentages for categorical variables and mean ± standard deviation (SD) for continuous variables.² The correlation between AHF on admission and the 30-day mortality window was examined by logistic regression analyses.² The main outcome measures were the occurrence of AHF corresponding to Killip class and the rate of 30-day all-cause mortality in individuals presenting with AHF.²

The results showed that 12.6% (n=1,824) of participants were statin users, who had the following baseline characteristics: were often former smokers, had greater body mass index (BMI), more frequently had diabetes, hypertension and hypercholesteremia, and were more likely to have received concomitant evidence-based medications before hospital admission.²

Prior statin use had a significant decreased occurrence of AHF at the time of ACS admission (absolute difference: 4.3%; RR=0.72; 95% CI: 0.62-0.83), regardless of younger (40-75 years) or older age (interaction p=0.27) and gender (interaction p=0.22).² Prior statin use predicted a lower risk of 30-day mortality in statin users vs. statin non-users (15.5% vs. 20.7%; RR=0.71; 95% CI: 0.50-0.99).² This advantage was not seen in patients without AHF on admission.² Prior statin use correlated with a significantly lower risk of presenting with STEMI (RR=0.64; 95% CI: 0.58-0.71^).2

​​​​​​Besides, the absolute risk of developing AHF on hospital admission of ACS decreased by approximately 4%.² Notably, it was found that statin use predicted a lower risk of 30-day mortality in individuals presenting with AHF on admission after ACS (5.2% absolute risk and 29% RR reduction).² This is an important finding because it provides additional data on the mechanistic process correlating statin therapy to a reduction in mortality due to ASCVD.²

In conclusion, there are 2 benefits of statin therapy, i.e., a reduced percentage of patients having AHF on admission; and statin users with AHF on presentation with ACS had reduced mortality, as compared with statin non-users with AHF on presentation with ACS.² Thus, previous statin therapy in patients presenting with ACS as the first manifestation of ASCVD was associated with a reduced risk of AHF and improved patient survival from AHF.² This knowledge may be beneficial to individuals who do not have established CVD, but may be at the risk of future CVD events, in terms of treating them with statins in a preventative primary setting.¹

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