Are statins indicated in congestive heart failure (CHF) and cardiomyopathy?

From the Guidelines

Statins are not routinely indicated for heart failure (CHF) or cardiomyopathy unless there are other compelling indications such as atherosclerotic cardiovascular disease or high cholesterol levels. The most recent and highest quality study, 1, suggests that statin therapy is not routinely recommended for individuals with NYHA class II to IV HF. However, patients with ischemic cardiomyopathy who are already on statins may be continued on them, and statins should be considered in patients with HF presenting with acute ischemic events or with evidence of significant myocardial ischemia.

Some key points to consider in the management of CHF and cardiomyopathy include:

• The routine use of statins to treat HF of any type is not indicated outside the current practice guidelines for the primary and secondary prevention of atherosclerotic vascular disease, as stated in 1.
• Statin therapy may be appropriate for patients with ischemic cardiomyopathy as secondary prevention of coronary events, as suggested in 1 and 1.
• For non-ischemic cardiomyopathy without other indications, the evidence does not support routine statin therapy, as noted in 1.
• If a patient with heart failure has other indications for statins such as established atherosclerotic disease, diabetes with high cardiovascular risk, or significantly elevated LDL cholesterol, then statin therapy would be appropriate regardless of the heart failure diagnosis, as implied in 1 and 1.

In terms of specific guidelines, the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, referenced in 1, does not recommend statin therapy for individuals with NYHA class II to IV HF. However, the 2013 ACCF/AHA Guideline for the Management of Heart Failure, referenced in 1, suggests that statins should be used in patients with a recent or remote history of MI or ACS to prevent symptomatic HF and cardiovascular events.

Overall, the decision to use statins in patients with CHF and cardiomyopathy should be based on individual patient factors and the presence of other compelling indications, rather than routine use for heart failure alone, as supported by the evidence in 1 and 1.

From the FDA Drug Label

The reduction in the rate of CHF with hospitalization was only observed in the 8% of patients with a prior history of CHF Of the predefined secondary endpoints, treatment with atorvastatin calcium 80 mg/day significantly reduced the rate of coronary revascularization, angina, and hospitalization for heart failure, but not peripheral vascular disease.

Statins in CHF and Cardiomyopathy:

• Statins, such as atorvastatin, may be beneficial in reducing the rate of hospitalization for heart failure in patients with a prior history of CHF.
• The reduction in hospitalization for heart failure was observed in patients treated with atorvastatin calcium 80 mg/day.
• However, the data does not provide direct evidence for the use of statins in cardiomyopathy.
• The FDA drug label for atorvastatin calcium does provide some evidence for the reduction of hospitalization for heart failure, but this is limited to patients with a prior history of CHF 2.

From the Research

Statins in CHF and Cardiomyopathy

• Statins have pleiotropic effects beyond cholesterol lowering, including improving endothelial function, antioxidant and anti-inflammatory effects, and regulating neovascularization 3.
• Experimental evidence suggests that statins may be beneficial in heart failure by inhibiting myocardial hypertrophy, reducing cardiomyocyte loss by apoptosis, and reducing oxidative stress 3.
• Small randomized clinical trials have shown that short-term statin administration may improve key pathophysiological aspects of heart failure syndrome 3.
• Retrospective analyses of large statin trials imply a long-term benefit on clinical outcome in heart failure patients, but these results need to be reviewed with caution 3.

Considerations for Statin Therapy in CHF

• Low levels of cholesterol are associated with increased mortality in patients with chronic heart failure (CHF), which is a phenomenon of reverse epidemiology 4.
• Statins may have a harmful effect in patients with CHF due to their cholesterol-lowering properties, but they also have pleiotropic effects that may be beneficial 4.
• The pharmacological mechanisms of statin treatment need to be examined to reconcile the contradictory lines of evidence 4.

Statins in Dilated Cardiomyopathy

• Inflammation plays a role in the development and progression of congestive heart failure (CHF) in patients with dilated cardiomyopathy (DCM) 5.
• Statins have shown promising results in patients with cardiomyopathies by inhibiting inflammation, alleviating endothelial damage, and reducing endothelial dysfunction 5.
• Candidates for statin therapy with DCM should be in New York Heart Association class II or III and have normal or increased levels of lipids 5.

Current Evidence and Future Directions

• The efficacy of statins in reducing morbidity and mortality in patients with documented coronary artery disease is unquestionable, but evidence regarding their beneficial effects in CHF remains contradictory 6.
• Further randomized clinical trials are needed to confirm the beneficial effect of statins on cardiovascular outcome in CHF patients and to elucidate the contributing mechanisms 3, 6.
• The association between cholesterol and mortality in heart failure is complex and depends on the presence or absence of coronary artery disease 7.