Statin therapy in heart failure: for good, for bad, or indifferent?

Statins are effective in the prevention of coronary events and the treatment of acute coronary syndromes. However, their efficacy and safety in patients with heart failure (HF) is still a matter of debate. On the basis of literature evidence from subgroup analysis, retrospective, prospective cohort studies, and randomized controlled trials, in this review we try to answer the following question: Is statin therapy in HF patients for good, for bad, or indifferent? Some studies showed a negative impact of low cholesterol levels in patients with severe HF (endotoxin-lipoprotein hypothesis and coenzyme Q10 hypothesis). On the other hand, a large amount of literature demonstrates that in patients with HF, statins have a positive impact on survival and other outcomes, regardless of whether the HF was of ischemic or nonischemic origin, which is related to a combination of mechanisms (pleiotropic effects and cholesterol reduction). Much of this evidence, however, comes from observational and retrospective studies and subgroup analyses of statin use in patients with HF. Randomized clinical trials examining the efficacy of statins in HF (GISSI-HF and CORONA) did not show a benefit in mortality for patients with HF randomized to receive statins. Nevertheless, a meta-analysis found that statin therapy does not decrease all-cause or cardiovascular mortality but significantly decreases the rate of hospitalization for worsening HF and increased left ventricular ejection fraction compared with placebo.