The effect of statin use and intensity on stroke and myocardial infarction after carotid endarterectomy

Abstract

Objective: Statin use in patients with cerebrovascular disease undergoing carotid endarterectomy (CEA) has been advocated for prevention of stroke and cardiovascular events. However, the effect of statin therapy on long-term outcomes after CEA still needs to be delineated. Methods: OptumLabs Data Warehouse, a comprehensive, longitudinal, real-world dataset with deidentified lives across claims and clinical information, was used to analyze the rates of stroke, myocardial infarction (MI), and statin use after CEA. Both duration and intensity of statin therapy were investigated. Results: There were 21,277 patients who underwent CEA from 2004 to 2014. The average age was 70 years, and 59.4% were male. The average Elixhauser index score was 4.2. Follow-up was a median of 2.4 years (range, 0.2-10.0 years). Longterm statin use was observed in 57.4%. Statin distribution included atorvastatin 35%, simvastatin 35%, pravastatin 11%, rosuvastatin 10%, and lovastatin 7%. The 30-and 90-day stroke rates were 1.3% and 2.2%, and the MI rates were 0.5% and 1.1%, respectively. Postoperative statin use was associated with a lower perioperative stroke rate at 30 days (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.61-0.98; P ¼ .036) and 90 days (OR, 0.75; 95% CI, 0.62-0.90; P ¼ .002). Postoperative statin use did not show a protective effect on 30-day or 90-day MI rates (OR, 1.01; 95% CI, 0.69-1.46; P ¼ .975) or 90-day MI rates (OR, 0.85; 95% CI, 0.66-1.11; P ¼ .213). High-intensity statin use when compared with standard therapy did not affect 30-day stroke outcomes (OR, 0.96; 95% CI, 0.60-1.5; P ¼ .847) or 90-day stroke outcomes (OR, 1.06; 95% CI, 0.74-1.5; P ¼ .762); or 30-day MI (OR, 0.81; 95% CI, 0.39-1.68; P ¼ .576) or 90-day MI (OR, 1.25; 95% CI, 0.79-1.96; P ¼ .339). Statin use was independently protective against long-term stroke (hazard ratio, 0.82; 95% CI, 0.75-0.91; P < .001) and MI (hazard ratio, 0.83; 95% CI, 0.75-.92; P < .001). Conclusions: Postoperative statin use among patients undergoing CEA was associated with a decreased risk of stroke at 30 and 90 days, as well as a long-term protective effect against MI and stroke. High-intensity statin use compared with standard use did not show an effect on outcomes of stroke or MI at 30 and 90-days after CEA.

Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review

“…NR NR Tung et al (2017) [ 60 ] Taiwan National Health Research Insurance database from 2009 to 2012 AMI, UA, stroke, resuscitation after cardiac arrest, all cause death, cardiac revascularization procedure AMI: 410–410.9; UA: 411.1; stroke: 430–437; resuscitation after cardiac arrest: 427.5; revascularization: 36.0–36.03, 36.05–36.09, 36.1–36.99, V45.81 (ICD-9). NR NR Arinze et al (2018) [ 61 ] OptumLabs Data Warehouse from 2004 to 2014 AMI, stroke AMI: 410; stroke: 434, 434.0, 434.00, 434.01, 434.1, 434.10, 434.11, 434.9, 434.90, 434.91 (ICD-9). NR NR Baviera et al (2018) [ 62 ] Administrative health databases of Lombardy from 2002 to 2014 ACS, stroke, all cause death, major amputation ACS: 410.xx, 411; stroke: 430, 431, 434.xx, 436, 433.11; major amputation: 84.10, 84.13, 84.14, 84.15, 84.16, 84.17, 84.18, 84.19 (ICD-9).…”

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy

“…Similarly, Arinize et al demonstrated in 21,277 patients who underwent CEA from 2004 to 2014 that postoperative statin use was associated with lower perioperative stroke at 30 and 90 days (OR .77 [.61-.98]; OR .75 [.62-.90]). 22 Statin use was also shown to independently protect against long-term stroke (HR .82 [.75-.91]) and MI (HR .83 [.75-.92]). Our study shows a significant change in statin use over time, with the earliest era not prescribing statins postoperatively in 50.6% of cases while the current era does not prescribe only 10.0% of cases.…”

Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis

“…There has been a noticeable improvement in medical treatment for carotid stenosis, including the use of statins, in the last 20 years. [ 33 ] Additionally, the CEA procedure is more likely to be centralized in high-volume vascular centers with experienced surgeons. [ 34 ] Moreover, due to the development of CAS, CAS could be an alternative for some patients who are considered high risk for undergoing CEA.…”