Emre et al report that moderate-to-severe nonalcoholic fatty liver disease (NAFLD) is independently related with impaired myocardial perfusion and with poorer in-hospital prognosis after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction. In-hospital major adverse cardiac events (MACE) occurred in 31% versus 8% (p <0.0001) of patients with moderate-to-severe and mild NAFLD, respectively. NAFLD severity was evaluated with a semiquantitative score and was characterized as mild if the score was <3 or moderate to severe if the score was ≥3. Postprocedural myocardial perfusion was evaluated with myocardial blush grade and ST-segment resolution. In this context, we previously reported that NAFLD is related with excess risk of cardiac events both in patients with or without established cardiovascular disease. The Incremental Decrease in End Points Through Aggressive Lipid Lowering trial (n = 8,863) confirmed these findings. Post hoc analyses of the previously mentioned studies reported that high-dose atorvastatin was safe in patients with abnormal liver tests, probably because of NAFLD, reduced transaminase levels, and also reduced MACE twice more in these patients compared with those with normal liver biochemistry. Recently, we reported that monotherapy with rosuvastatin 10 mg/day ameliorated liver histology in biopsy-proved nonalcoholic steatohepatitis, an advanced/severe form of NAFLD, and resolved metabolic syndrome within 12 months.

All the previously mentioned findings urge us to suggest that preprocedural high-intensity statin load or reload might lead to a substantial reduction of MACE risk after PCI, especially in patients with acute coronary syndromes, as those in the study by Emre et al. In the former study, only 11% of patients with severe NAFLD were on statins before PCI. Statins might reduce the risk of acute kidney injury because of contrast-induced nephropathy, which is not rare in acute coronary syndromes treated with PCI and is associated with adverse cardiac outcomes and might also improve myocardial perfusion and reduce both MACE and periprocedural myocardial injury in patients undergoing PCI ; the earliest the statin administration before PCI, the greatest the benefits. This suggestion, if confirmed by prospective studies, will have practical implications in everyday clinical practice.