No benefits of statins for sudden cardiac death prevention in patients with heart failure and reduced ejection fraction: A meta-analysis of randomized controlled trials.

Muaamar Al-Gobari,Hai-Ha Le,Bernard Burnand,Mor Fall,François Gueyffier,Pasquale Abete

doi:10.1371/journal.pone.0171168

Abstract

Background and objectivesStatins showed mixed results in heart failure (HF) patients. The benefits in major HF outcomes, including all-cause mortality and sudden cardiac death (SCD), have always been discordant across systematic reviews and meta-analyses. We intended to systematically identify and appraise the available evidence that evaluated the effectiveness of statins in clinical outcomes for HF patients.DesignSystematic review and meta-analysisData sourcesWe searched, until April 28, 2016: Medline, Embase, ISI Web of Science and EBM reviews (Cochrane DSR, ACP journal club, DARE, CCTR, CMR, HTA, and NHSEED), checked clinicaltrials.gov for ongoing trials and manually searched references of included studies.Eligibility criteria for selecting studiesWe identified 24 randomized clinical trials that evaluated the efficacy of statins for HF patients. All randomized clinical trials were assessed for risk of bias and pooled together in a meta-analysis. Pre-specified outcomes were sudden cardiac death, all-cause mortality, and hospitalization for worsening heart failure.ResultsStatins did not reduce sudden cardiac death (SCD) events in HF patients [relative risk (RR) 0.92, 95% confidence interval (CI) 0.70 to 1.21], all-cause mortality [RR 0.88, 95% CI 0.75 to 1.02] but significantly reduced hospitalization for worsening heart failure (HWHF) although modestly [RR 0.79, 95% CI 0.66 to 0.94]. Nevertheless, estimated predictive intervals were insignificant in SCD, all-cause mortality and HWHF [RR, 0.54 to 1.63, 0.64 to 1.19, and 0.54 to 1.15], respectively. An important finding was the possible presence of publication bias, small-study effects and heterogeneity of the trials conducted in HF patients.ConclusionsStatins do not reduce sudden cardiac death, all-cause mortality, but may slightly decrease hospitalization for worsening heart failure in HF patients. The evaluation of the risk of biases suggested moderate quality of the published results. Until new evidence is available, this study supports the 2013 ACCF/AHA guidelines to not systematically prescribe statins in “only” HF patients, which should help avoid unnecessary polypharmacy.

Highlights

Heart failure (HF) patients are likely to take more than one drug and tend toward polypharmacy
Statins did not reduce sudden cardiac death (SCD) events in heart failure (HF) patients [relative risk (RR) 0.92, 95% confidence interval (CI) 0.70 to 1.21], all-cause mortality [RR 0.88, 95% CI 0.75
All funding is independent from the study design, data interpretation, writing or the decision to submit the article for publication

Summary

Introduction

Heart failure (HF) patients are likely to take more than one drug and tend toward polypharmacy. Guideline-directed medical therapy includes angiotensin converting enzyme inhibitors, betablockers, aldosterone antagonists as well as implantable cardioverter defibrillators, which all have reported a reduction in mortality and morbidity in heart failure patients [1,2,3,4]. Though, such benefits are still insufficient to the current management need as almost half of HF patients die within 5 years after initial diagnosis and half of the mortality is attributed to sudden cardiac death (SCD) [5,6]. We intended to systematically identify and appraise the available evidence that evaluated the effectiveness of statins in clinical outcomes for HF patients

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Results

Conclusion