Should a statin be held in a person with severe Heart Failure with reduced Ejection Fraction (HFrEF) and impaired renal function, specifically with an estimated Glomerular Filtration Rate (eGFR) of severe impairment?

From the Guidelines

In patients with severe heart failure with reduced ejection fraction (HFrEF) and severely reduced kidney function (eGFR of 13), statins should generally be continued rather than held, unless there are specific contraindications such as rhabdomyolysis, severe myopathy, or significantly elevated liver enzymes. For patients already on statin therapy, the benefits of continuing treatment typically outweigh the risks, even with advanced kidney disease. However, dose adjustment may be necessary - lower doses of hydrophilic statins like rosuvastatin (5-10mg) or atorvastatin (10-20mg) are preferred in severe kidney disease. Close monitoring is essential, including regular assessment of creatine kinase, liver function tests, and symptoms of myopathy such as muscle pain or weakness. The rationale for continuing statins in this population includes their pleiotropic effects beyond cholesterol lowering, including anti-inflammatory properties and improved endothelial function, which may benefit heart failure patients. While initiating new statin therapy in patients with both severe HFrEF and advanced kidney disease remains controversial, discontinuation in those already tolerating the medication is generally not recommended based on kidney function alone, as supported by the most recent guidelines 1. It's also important to consider the patient's overall clinical status and other comorbidities, as well as the potential benefits and risks of statin therapy, as outlined in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. Additionally, the 2013 ACCF/AHA guideline for the management of heart failure emphasizes the importance of individualized treatment decisions, taking into account the patient's specific needs and circumstances 1. In summary, the decision to continue or discontinue statin therapy in patients with severe HFrEF and advanced kidney disease should be made on a case-by-case basis, considering the potential benefits and risks of treatment, as well as the patient's overall clinical status and other comorbidities.

From the Research

Statin Use in Severe HFrEF with Low eGFR

• The use of statins in patients with heart failure with reduced ejection fraction (HFrEF) and low estimated glomerular filtration rate (eGFR) is a complex issue, with limited direct evidence available 2, 3.
• A study published in F1000Research in 2021 found that statins may be effective in improving survival and other clinical outcomes in patients with HFrEF, although the evidence is not conclusive 2.
• Another study published in CJC open in 2022 discussed the management of HFrEF in patients with chronic kidney disease (CKD) and noted that the presence of CKD should not preclude the use of certain medications, but that careful monitoring of renal function and potential toxicity is necessary 3.
• Regarding the specific question of holding a statin in a person with severe HFrEF and an eGFR of 13, there is no direct evidence available to provide a clear answer.
• However, a study published in the International journal of cardiology in 2013 found that atorvastatin and rosuvastatin had similar reno-protective effects in patients at high cardiovascular risk, with comparable rates of new onset proteinuria when commonly used doses are considered 4.
• It is also worth noting that the study published in F1000Research in 2021 suggested that statins did not cause harm and should be continued in HF patients who are already taking the medication, although this may not directly apply to patients with very low eGFR 2.

Considerations for Statin Use in Low eGFR

• The decision to hold or continue a statin in a patient with severe HFrEF and low eGFR should be made on a case-by-case basis, taking into account the individual patient's clinical status and potential risks and benefits 3.
• Patients with HFrEF and CKD require careful management, including monitoring of renal function and potential toxicity, as well as consideration of the potential benefits and risks of different medications 3.
• The study published in CJC open in 2022 noted that sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m2, highlighting the importance of considering renal function when making treatment decisions 3.
• Further research is needed to clarify the benefits and risks of statin use in patients with HFrEF and low eGFR, as well as to provide more specific guidance for clinicians making treatment decisions in this population 2, 3.