Statin loading before percutaneous coronary intervention to reduce periprocedural myocardial infarction

Periprocedural myocardial infarction (PMI) is a common complication associated with percutaneous coronary intervention (PCI), occurring in approximately 15% to 20% of patients undergoing the procedure. The established diagnostic criteria for PMI is an increase in cardiac biomarkers, specifically creatine kinase-MB levels > 3 times the upper limit of normal. As PMI has been associated with an increased risk of mortality after PCI, investigative efforts have been directed at therapies that can potentially decrease PMI. One such therapy is the use of hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) administered as a loading dose before PCI. Multiple small, randomized, controlled trials have demonstrated significant reductions in the incidence of PMI with statin loading before PCI. The risk reduction was seen in patients with stable and unstable coronary artery disease, as well in statin-naive patients or those on chronic statin therapy. Potential mechanisms for the rapid benefits of statin loading include: anti-inflammatory effects, reversal of endothelial dysfunction, decrease in oxidative stress, and inhibition of the thrombotic system. None of the current studies were of sufficient power or duration to detect benefits on mortality, though a recent meta-analysis did demonstrate a reduction in major adverse cardiovascular events. In addition to long-term effects, several additional questions remain with regard to statin loading, such as statin type, dose, and optimal timing of administration. However, given the current evidence of benefit and the low risk of adverse events, it can be recommended that all patients undergoing PCI be considered for statin loading before the procedure.