Patients undergoing acute coronary syndrome (ACS) loaded with a high dose of statins prior diagnostic catheterization do not seem to benefit from this strategy.
However, when looking at those undergoing PCI alone (excluding all patients who had received surgery or medical treatment), the benefit appears as a reduction of combined major events. The benefit of atorvastatin loading prior procedure seems to be driven by a reduction of unrelated MI.
The SECURE-PCI, presented at ACC 2018 scientific sessions and simultaneously published by JAMA, should be interpreted globally as a negative study where favorable outcomes were observed only in a subgroup of patients. Even though this has been prespecified in the protocol, it should be regarded as no more than a hypothesis generator.
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Outcomes are consistent with other small study outcomes and this benefit seems logical, especially in patients undergoing ACS.
Studies such as the PROVE-IT and the IMPROVE-IT have shown the benefit of intensive care with statins within 7 days after ACS in PCI patients. The present study reduces this benefit even more and starts treatment before revascularization. We could challenge the benefit of this course of action but the fact that there were no adverse effects puts us at ease.
The SECURE-PCI was carried out in 53 centers in Brazil and randomized 4191 patients undergoing ACS assessed with angiography to receive 80mg load of atorvastatin vs placebo prior PCI and 24 hrs. after PCI. Both branches continued with 40 mg atorvastatin after the second dose of medication.
Read also: ACC 2018 | SMART-DATE: 6 Month DAPT Results Suboptimal in ACS.
When looking at the remaining 2710 finally treated with PCI, we find that atorvastatin preloading was associated with a 28% reduction of combined end points, compared to placebo (p=0.02) and a reduction of 32% of MI risk (p=0.04), including a 58% reduction of unrelated MI.
Original title: Effect of loading dose of atorvastatin prior to planned percutaneous coronary intervention on major adverse cardiovascular events in acute coronary syndrome: the SECURE-PCI randomized clinical trial.
Reference: Berwanger O et al. JAMA. 2018; Epub ahead of print.
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