Posted on September 9, 2015
The Swedish Heart Failure Registry (RiksSvikt) has been in use since 2000. Over 80 clinical variables are collected of HF patients at discharge from the hospital and/or after out-patient consultation annually. Propensity scores for treatment with statins were estimated using 40 baseline variables. Population matched 1:1 based on age and propensity score. Data was collected from May 11, 2000 until May 11, 2012. There were 46,959 unique registrations. The study cohort consisted of 9 140 patients. Statins were used by 3 427 (37.5%) and 5 713 (62.5%) did not.
In the statin treated patients 1-year survival was 85.1% vs 80.9% in the untreated cohort. HR:
0.80 (95%CI 0.72-0.89, p<0.001). Cardiovascular death HR: 0.86, (95%CI 0.75-0.98, p: 0.026), and composite all-cause mortality or cardiovascular hospitalization HR: 0.89, (95%CI 0.82-0.96, p:0.003). The number needed to treat [NNT] for one year in order to prevent one death from any cause was 29. After 3 years survival was 66.1% (95%CI 63.8-68.6%) vs. 61.3% (95%CI 58.9-63.8%), NNT 16 and after 5 years 52.9% (95%CI 49.8-56.2%) vs. 45.0% (95%CI 41.7-48.5%), NNT 23<
In patients with preserved ejection fraction (>50%) statin use was associated with improved survival and cardiovascular death and cardiovascular hospitalizations.
Strengths – Weakness
The RisksSvit is the largest heart failure registry in the world. Despite the large patient number, long duration of follow-up, and extensive covariate availability for matching, and adjustment for propensity scores residual confounding cannot be ruled. Information that was lacking in the registry: statin type, dose and adherence; hsCRP levels; LDL-C levels; use of other potential confounding medications as steroids and non-steroidal anti-inflammatory drugs.
“In this study we raise the possibility that while statins have no role in HFREF without IHD, the potential benefit in IHD may still not be ruled out. In contrast, in the HFPEF population studied here, no such interaction with IHD was observed, with an associated benefit regardless of IHD”.
There is a clear lack of understanding on whether statins provide benefit in patients with preserved ejection fraction and suffering from diastolic HF. The two statin HF trials: CORONA and GISSI HF, included predominantly patients with systolic HF and showed now benefit. In the ACC/AHA guidelines 2013 on management of heart failure that statins are not advised because no benefit has been shown. No specific recommendations are given regarding statin treatment in HFPEF. Given the complexity of HFPEF and observational data that show benefits in this distinct group of HF patients, the high prevalence, poor prognosis and lack of current therapy, in HFPEF a RCT would be warranted
Association Between Use of Statins and Mortality in Patients With Heart Failure and Ejection Fraction of Greater Than or Equal to 50. Alehagen U, Benson L, Edner M et al. Circ Heart Fail 2015; PMID: 26243795.