Use of statins, renin-angiotensin system inhibitors may improve 3-year survival after TAVR

Alexander C. Fanaroff, MD

The most important take-home message from this study appears to be that patients who filled prescriptions for statins and ACE inhibitors had lower 3-year post-TAVR mortality than those who did not. To me, this could mean a few things: 1) Statins and ACE inhibitors themselves improve outcomes in post-TAVR patients; 2) Patients who fill prescriptions for medications after TAVR have better outcomes; or 3) Patients with cardiologists who are thinking about and managing the entirety of their risk for CVD have better outcomes than those who do not. With that in mind, the most important take-home message is that medical therapy for CVD after TAVR still matters.

I’m not sure you can say from this study that these prescriptions truly affected 3-year survival. This is an observational study using claims data, so the authors’ ability to understand why patients did and did not fill prescriptions for statins and ACE inhibitors is limited by the absence of detailed clinical and sociodemographic data. This limits their ability to adjust for all possible confounders (variables that affect both likelihood of filling a prescription for statins and ACE inhibitors after TAVR, and 3-year mortality), raising the possibility of residual confounding causing the observed association between statins/ACE inhibitors and 3-year mortality, rather than any effect of the medications themselves.

A TAVR, like a PCI or any other CV, is an opportunity to get patients into CV care. Even though we may be interventional cardiologists, we have an opportunity (and a responsibility) to care for all of our patients’ cardiovascular conditions (or to find them a general cardiologist who will). If we want to make the largest difference in our patients’ lives, our work isn’t done after we close the arteriotomy post-TAVR. For hospital systems, a TAVR procedure is an opportunity to get patients into care, and developing systems to do so is worthwhile.

This study is hypothesis-generating. I won’t necessarily start my post-TAVR patients on ACE inhibitors or statins on the basis of this study. What I will do is review their indication for these medications (and others important for the primary and secondary prevention of CVD) and start them when indicated, but that’s the sort of thing we should already be doing. On the research side, a study like this does argue for randomized controlled trials dedicated to answering the question of whether statins or ACE inhibitors improve outcomes after TAVR.