Preoperative statin therapy has a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair that reduces risk and subsequent total hospital costs according to a new study from researchers at the East Carolina Heart Institute in Greenville, North Carolina.
Published in the June issue of the Society of Vascular Surgery's®, Journal of Vascular Surgery®, this retrospective review compares 401 patients who underwent an elective endovascular aortic aneurysm repair (EVAR) or open AAA repair (OAR) between 2004 and 2007. Clinical endpoints included postoperative days; length of hospital stay; postoperative complications (myocardial infarction, stroke, renal failure, hemorrhage, pneumonia, and urinary tract and wound infections); 30-day mortality; and total hospital cost associated with the procedures.
"Both groups (173 EVAR and 228 OAR) were evenly matched with the only significant differences being that the EVAR cohort was older and patients with end-stage renal disease were only offered EVAR repair," said Michael C. Stoner, MD, RVT, FACS, Associate Professor of Cardiovascular Sciences, East Carolina University. "EVAR patients were also more likely to be on a statin or beta blocker before surgery."
Dr. Stoner noted that despite a higher Society for Vascular Surgery risk score, the EVAR statin cohort had significantly reduced postoperative days (1.9 +/- 0.2 vs. 2.3 +/- 0.3) and hospital length of stay (2.3 +/- 0.3 vs. 2.8 +/- 0.4) compared to the non-statin EVAR cohort. Postoperative complications (4.4 percent vs. 14.7 percent) and mortality (0.0 percent vs. 5.9 percent) were significantly decreased in the open statin cohort compared to the non-statin open cohort, and trended to be decreased in the EVAR statin group. Importantly, he said, use of statin therapy translated into improved total cost per patient in both treatment groups ($3,205 a case for EVAR and $3,792 a case per OAR).
Researchers said there were no 30-day deaths in the statin EVAR group despite equal rates of myocardial infarction between the cohorts, which could be due to the protective benefit of these agents in the coronary vascular bed and their ability to limit the extent of myocardial ischemic injury.
"We found that overall statin use in this study was quite low (40.4 percent for OAR and 51.4 percent of EVAR," added Dr. Stoner. "This might suggest a heterogeneous access to care, because a relatively small percentage of patients were receiving appropriate medical therapy at time of referral, most likely related to the low socioeconomic status and geographic barrier to care seen in rural academic practices such as ours."
"Prior to this study, the authors tended not to start AAA patients on statins but simply recommended their use. This was communicated back to the referring or primary doctor at the time of consultation," said Dr. Stoner. "Now we initiate statin pharmacotherapy for all elective AAA patients at the initial consultation, based on Class II American Heart Association guidelines, unless there is a specific contraindication, regardless of lipid profile. The therapy is continued through the operation until the first postoperative visit. We then make a recommendation to continue medical therapy with the patient's primary physician. We are currently following this practice change in a prospective manner and will report on its impact." The researchers did acknowledge the potential confounding issues associated with retrospective studies such as this.
In the United States, AAA's are the 13th and 16th leading causes of death, respectively, in men and women 65 years and younger in the United States. With approximately 35,000 to 40,000 AAA's being repaired annually, the effect of existing perioperative therapies should be optimized in order to provide safer and more cost-effective care, said Dr. Stoner. "Evidence examining statin therapy in elective AAA repair has been limited," he added, "but our study showing improved patient outcomes and lower overall health care cost suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing this procedure."
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