Comment on: “Prior Treatment with Statins is Associated with Improved Outcomes of Patients with COVID-19: Data from the SEMI-COVID-19 Registry”

Abstract

We found the multicenter registry study by Torres-Peña et al. [1] very interesting and well organized. The authors were able to show that hospitalized COVID-19 patients who maintained long-term statin treatment that had been initiated before hospitalization had better prognoses when measured by all-cause mortality, acute respiratory distress syndrome, and acute kidney injury. For example, all-cause mortality was 20.6% for those continuing on statins and 27.6% for those who withdrew from statins (P < 0.001). The patient data showed that there were altogether 1130 patients in the study who continued in-hospital statin use and 1791 patients who withdrew statin use in the hospital. It can be calculated that over 60% of hospitalized patients with COVID-19 had for unknown reasons stopped their statin consumption during the hospitalization period. This is an astonishingly large number of patients; however, the authors did not comment on this aspect. Who then are these patients who were on chronic statin treatment before hospitalization for COVID-19? According to lipid treatment guidelines, the initiation of statin treatment is targeted to those who have a significantly elevated risk for atherosclerotic cardiovascular disease (ASCVD) [2]. The real-world example of 541,221 non-COVID-19 patients who were on statins included those in the diabetes cohort (61.1%), followed by those who had a recent acute coronary syndrome (ACS) event (15.8%), recent non-ACS cardiovascular (CV) event (9.9%), peripheral artery disease (4.7%), coronary heart disease (4.4%), or history of ischemic stroke (4.1%) [3]. In another recent study of hospitalized COVID-19 patients (N = 951) who were antecedent statin users, 74% had hypertension, 55.8% had diabetes, 22.5% had coronary artery disease, and 13.9% had a history of stroke/ transient ischemic attack [4]. The respective significantly smaller percentages for non-statin users were 43.3%, 26.1%, 6,9%, and 5.6%. Based on the data presented above, any discontinuation of statin therapy, even temporarily, is potentially detrimental to a patient with a cardiovascular risk profile that, according to the current guidelines, is an indication for statin treatment. It has been shown in a recent population-based cohort study in France among 75-year-old non-COVID-19 patients treated for primary prevention that the adjusted ratios for statin discontinuation were 1.33 (95% confidence interval (CI) 1.1.8–1.50) for any cardiovascular event, 1.46 (95% CI 1.21–1.75) for a coronary event, and 1.26 (95% CI 1.05–1.51) for a cerebrovascular event [5]. It should be noticed that these risks were seen in this older population who did not have clinical signs of ASCVD. Among the statin-treated patients, some individuals have an inherited cholesterol disease such as heterozygous familial hypercholesterolemia (HeFH), in which the serum low-density cholesterol (LDL-C) is elevated twoto threefold since birth [6]. The prevalence of HeFH is about one out of 250 individuals in the general population [7]. If left untreated with a statin, HeFH patients develop premature atherosclerosis and results in an approximate tenfold increase in the risk of early ASCVD [8]. Accordingly, among the HeFH population, the risk of discontinuation of statin treatment is potentially detrimental. This comment refers to the article available at https:// doi. org/ 10. 1007/ s4026502101498-x.