Statin therapy in patients with heart failure
- Prakash C Deedwania, MD
Prakash C Deedwania, MD
- Professor of Medicine
- University of California San Francisco School of Medicine
Statin therapy is widely used for both the secondary and primary prevention of atherosclerotic cardiovascular disease. However, the randomized trials that have provided evidence of benefit have included few patients with heart failure (HF) [1,2]. However, two major randomized trials, CORONA and GISSI-HF, have directly addressed this issue in patients with systolic HF. In addition, HF management is potentially complicated by the observation that low serum cholesterol is associated with worse outcomes.
These issues will be reviewed here. The role of statin therapy in the broad group of patients with cardiovascular disease and the multiple mechanisms by which statins might act in addition to cholesterol lowering are discussed elsewhere. (See "Treatment of lipids (including hypercholesterolemia) in primary prevention" and "Treatment of lipids (including hypercholesterolemia) in secondary prevention" and "Statins: Actions, side effects, and administration" and "Mechanisms of benefit of lipid-lowering drugs in patients with coronary heart disease".)
SERUM CHOLESTEROL AND PROGNOSIS IN HF
A low serum cholesterol in patients with heart failure (HF) is associated with higher mortality [1,3,4]. The following observations illustrated the range of findings:
●In a retrospective review of 1134 patients with advanced, chronic HF (almost all New York Heart Association [NYHA] class III or IV) (table 1), mean left ventricular ejection fraction [LVEF] 22 percent), the serum cholesterol was higher in survivors compared to nonsurvivors at one year . Patients in the lowest quintile of serum cholesterol (<129 mg/dL [3.3 mmol/L]) had an adjusted relative mortality risk of 2.1 compared to those in the highest quintile (serum cholesterol >223 mg/dL [5.8 mmol/L]). Low cholesterol appeared to be a marker for more severe disease, since these patients also had other findings known to predict worse outcomes in patients with HF, including lower serum albumin, lower serum sodium, and lower LVEF. (See "Predictors of survival in heart failure due to systolic dysfunction" and "Prognosis of heart failure".)
●A relationship between lower serum cholesterol levels (less than 200 mg/dL [5.2 mmol/L] and higher mortality was also found in a multivariable analysis of 114 patients with chronic HF . The multivariable model was validated in a second group of 303 additional patients with HF. The findings were independent of the etiology of HF.
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