Reply to the Letter to the Editor Letter to the Editor Reply to Paraskevas

In reaction to ‘Prescribing statins in aortic stenosis: Little to lose, much to gain’ [1], we would like to provide the readership of this journal with some additional information concerning statin use — or underuse — in our study population. In our observational prospective cohort study, we described treatment strategies in symptomatic patients with severe aortic stenosis in the Rotterdam area, the Netherlands [2]. In the patients observed, the so-called medical or conservative treatment was mostly aimed at relief of symptoms by diuretics, treatment of atrial fibrillation and systemic or pulmonary hypertension. To prevent endocarditis, all patients were treated with prophylactic antibacterial treatment before starting non-sterile surgical procedures. Approximately only half of the patients received lipidlowering drugs: 54% of the 76 patients in the aortic valve replacement (AVR) group and 47% of the 101 patients in the ‘medical/conservative’ group. Although we only documented drug prescriptions and have not studied why certain patients received statins (and why many did not), we doubt statin usage was aimed at slowing the progression of aortic stenosis. It is more likely statins were prescribed for (cardio-)vascular co-morbidity or dyslipidaemia. Statins may interfere with the progression of aortic stenosis, but to what degree and until which disease stage remains uncertain and has yet to be established in larger prospective series. Dr Paraskevas refers to a cohort study in which statins slowed the haemodynamic progression in patients with asymptomatic moderate-to-severe aortic stenosis [1], others reported no clear effect on the progression of moderate-to-severe aortic stenosis in a recent randomised trial [3]. Further, the SEAS trial he refers to, concerned patients with asymptomatic mild-to-moderate aortic stenosis [1,4]. In his comprehensive review, Dr Paraskevas concludes statins improve cardiovascular outcomes in surgical patients (either coronary artery bypass graft (CABG) or patients who need valve replacement or other thoracic surgery) [5]. However, it remains to be seen whether statin therapy is useful in the cohort we studied: the symptomatic patient with severe aortic stenosis in whom the decision to operate or not is yet to be made. Although interesting, this will be difficult to study because co-morbidities, age, the advanced state of the valve stenosis and treatment selection probably play a major role in clinical outcome. On the other hand, of course, one could also argue there is not much to lose. Since we have no hard data of our own to either support or reject this statement, we leave this subject open for debate. Nevertheless, we are grateful for Dr Paraskevas’ enthusiastic comments and discussion [1].