The role of statins in heart failure

HMG CoA reductase inhibitors (statins) have an established place in the treatment of coronary artery disease. However, their role in the treatment of heart failure (HF), including HF due to coronary artery disease, has been controversial since beneficial as well as possible harmful effects may occur. Several recent studies lend support for a beneficial effect of the statins in HF. These include: (i) post hoc subgroup analyses of prospective randomized clinical trials of statin therapy among patients with stable coronary artery disease where statins reduce the incidence of new HF; (ii) subgroup analysis of the evidence of statin use in large HF trails with different medication and medical devices; (iii) retrospective observational studies of statin use in HF; and (iv) prospective randomized clinical trials of statins in non-ischemic. Beneficial effects include attenuation of cardiac hypertrophy, improvement in endothelial function, anti-inflammatory effects, reduction in the activity of matrix metalloproteinases, reduction in apoptosis, interference with neurohormones, and improved homeostasis. However, there are also theoretical concerns about statins in HF, and existing literature for their safety and efficacy in HF patients has been limited by the retrospective or observational nature of these analyses, examination of incompletely validated surrogate endpoints and small prospective studies in subgroups of HF subjects. In contrast with the normal population, low concentrations of LDL and total cholesterol are associated with a worse prognosis in HF patients and a possible mechanism is reduction in ubiquinone (coenzyme Q10) levels, which is required for oxidative phosphorylation in cells. The safety aspect of these drugs in HF patients needs to be answered before statins can be recommended as a routine drug. For the moment there are several large-scale prospective outcome studies in HF which probably will give us more definitive answers.