Statin Pre-Treatment for the Prevention of Peri-Procedural Events in Carotid Artery Stenting

Recent randomized studies have shown that the rates of combined peri-procedural events for carotid artery stenting and carotid endarterectomy are similar. While the final numbers are similar, the actual events are different: more infarction events for endarterectomy and more stroke (particularly minor stroke) events for carotid artery stenting. The reduction of these rates of stroke has been the aim of many devices but few drugs.

Statins are used extensively, not only for their cholesterol-reducing effects, but also for their pleitropic effects. Furthermore, there is clear evidence that they reduce the risk of infarction and new stroke in patients admitted with stroke.

Pre-treatment with statins reduces the risk of peri-procedural infarction in coronary angioplasty, and of stroke and death in carotid endarterectomy.

Also read: “Early Endarterectomy Seems Superior to Carotid Stenting in Symptomatic Patients.”

Notably, there is evidence for statins in all of the aforementioned clinical contexts except for carotid artery stenting. That is the reason behind this study, aimed at testing their usefulness and also at establishing the necessary dose, should they be effective.

This work enrolled 397 patients with symptomatic carotid artery stenosis (≥50% stenosis on conventional angiography) treated with carotid artery stenting at 2 university hospitals. The definition of peri-procedural complication included any stroke, myocardial infarction, and death within 1 month after the procedure.

Statin pre-treatment was divided into three categories according to the atorvastatin dose administered: none (n = 158; 39.8%), standard dose (<40 mg of atorvastatin, n = 155; 39.0%), and high dose (≥40 mg; n = 84; 21.2%).

Also read: “Carotid Stenting or Endarterectomy? Considering Vascular Anatomy…”

The peri-procedural complication rates across the three dose categories were 12%, 4.5%, and 1.2%, respectively.

After adjustment, there was a change in the atorvastatin dose category that was inversely proportional to the rates of risk of complications (no statins vs. standard-dose statins: odds ratio [OR] 0.24; vs. high-dose statins: OR 0.11; p for trend = 0.01).

Administration of antiplatelet drugs was also an independent factor in peri-procedural complications (OR 0.18), although it is highly unlikely that a physician will forget to indicate these drugs (as opposed to statins).

Conclusion

This study shows that statin pre-treatment might reduce the incidence of peri-procedural complications dose dependently in patients with symptomatic carotid artery stenting.

Editorial

Current clinical practice guidelines do not recommend the use of statins before carotid artery stenting and, thus, do not mention a specific dose. However, that is a mere consequence of a lack of evidence (so far).

The rate of complications in symptomatic patients in this work was 6.8%, which is similar to previously published figures. However, for the high atorvastatin dose group only, the risk rate was less than half that percentage (3.3%).

This dose-dependent impact could be explained by the pleitropic (anti-thrombotic and pro-fibrinolytic) effect of statins, since no relation was found between cholesterol levels and events.

Symptomatic plaque is undoubtedly vulnerable and unstable, and statins could stabilize it and reduce embolic debris.

Original title: Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting.

Reference: Jeong-Ho Hong et al. Stroke. 2017 Jul;48(7):1890-1894.

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