Archief Roodbont

In the ARMYDA trials, a loading dose of atorvastatin reduced cardiac events after percutaneous coronary intervention in statin-naive patients whether they had stable angina or acute coronary syndromes (JW Cardiol May 9 2007). Might atorvastatin reloading before PCI also improve clinical outcomes in patients already taking statins?

To find out, the ARMYDA investigators randomized 383 patients on statin therapy (mean duration, about 9 months) to receive placebo or atorvastatin before scheduled PCI (80 mg 12 hours before angiography and 40 mg 2 hours preprocedure). About half the patients had ACS, and more than one third had diabetes. During 30-day follow-up, cardiac death, MI, or target-vessel revascularization occurred in 3.7% of statin-reload recipients and in 9.4% of placebo recipients (P=0.037). Periprocedural MI — defined as levels of a single measured biomarker (CK-MB or troponin I) >3 times baseline level or the upper limit of normal — occurred 2.4 times less often in statin-reload recipients than in placebo recipients. In a subgroup analysis, the between-group difference in the composite endpoint was significant only in patients with ACS (3.3% in statin-reload patients vs. 14.8% in placebo patients).

Comment: According to this study, the benefit of atorvastatin loading before PCI in statin-naive patients extends to patients on continuing statin therapy as well. Possible mechanisms producing this benefit include reduced endothelial activation, platelet inhibition, and anti-inflammatory and other effects independent of lipid-lowering. Although the clinical importance of a "small enzyme leak" after PCI is debated, the low risk of statin loading and the benefit now observed in multiple studies suggest that this therapy should become routine before PCI.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology August 19, 2009