*Purpose: This study aims to examine the efficacy of high-intensity statin therapy compared to low-intensity, moderate-intensity, or no statins at preventing cardiac allograft vasculopathy (CAV) and related outcomes of rejection and mortality after cardiac transplant in the setting of tacrolimus as primary calcineurin inhibitor (CNI).

*Methods: This single-center retrospective cohort analysis included all adult heart transplants from March 2009 to July 2018. Patients were grouped by the intensity of statin therapy at post-operative day (POD) 180 including high-intensity (Group A) or no statin, low-, or moderate-intensity statin (Group B). Primary outcomes included one- and three-year incidence of a composite endpoint of CAV, biopsy-proven acute rejection (BPAR), and death. Secondary outcomes included the incidence of each outcome individually. Transplant events were excluded for death prior to POD180 or insufficient follow-up data.

*Results: Of 212 heart transplant events, 197 met criteria for the one-year analysis. The cohort was 78% male and 82% Caucasian with a median age at transplant of 55. History of ischemic cardiomyopathy was present in 50% of cases. All regimens contained a CNI at POD180 with the majority of patients (97%) on tacrolimus. Baseline characteristics were similar between groups. Twenty-one, 45, 102, and 29 patients were on no, low-, moderate-, and high-intensity statins, respectively. One-year incidence of the composite endpoint was 31.0% in Group A and 31.6% in Group B (p=NS). CAV occurred in 6.9% vs. 1.8% and BPAR occurred in 27.6% vs. 29.2% in Group A and Group B, respectively (p=NS for both). Death at one year occurred in none of the patients in Group A compared to 3 patients (1.8%) in Group B (p=NS). There were 151 transplant events included in the three-year analysis, of which 19, 40, 75, and 17 patients were on no, low-, moderate-, and high-intensity statins at POD180. Demographics were similar to those of the one-year analysis cohort. There was no difference in the composite outcome, occurring in 64.7% in Group A vs. 58.2% in Group B. At three years, CAV occurred in 29.4% vs. 13.43% and BPAR occurred in 47.1% vs. 36.6% in Group A and Group B, respectively (p=NS for both). Incidence of death at three years was lower in the high-intensity group with 1 occurrence compared to 20 (14.9%) in Group B. This difference was not statistically significant.

*Conclusions: In this cohort analysis, high-intensity statin therapy early after heart transplantation does not appear to be associated with a lower incidence of CAV, BPAR, or death at one or three years. While more patients and longer follow-up are necessary, these results may help guide therapy in statin-intolerant patients.

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