Statin Therapy Prior to CABG Reduces the Risk of Postoperative AF

April 20, 2012

April 20, 2012 (Cologne, Germany) — Statins administered prior to cardiac surgery significantly reduced the risk of postoperative atrial fibrillation and resulted in a significantly shortened length of stay in the intensive care unit (ICU), according to the results of a new meta-analysis [1]. Preoperative statin therapy had no effect on short-term mortality and postoperative stroke rates, however.

Overall, investigators are cautious in their interpretation of the results, noting that patients primarily were treated with atorvastatin and underwent CABG surgery, making extrapolations to other statins and different types of cardiac surgery difficult.

"Nonetheless, it appears reasonable and in compliance with existing guidelines to advocate an intensified preoperative statin treatment, followed by a rigorous postoperative reinitiation regimen, in all hyperlipidemic patients with multiple cardiac risks and coronary heart disease scheduled for cardiac surgery," write Dr Oliver J Liakopoulos (University of Cologne, Germany) and colleagues in a new review published online April 18, 2012 in the Cochrane Database of Systematic Reviews.

Data From Randomized, Controlled Trials

As reported previously by heartwire , the researchers have published results from a larger meta-analysis of patients undergoing cardiac surgery pretreated with statins, but many of these studies were observational. That analysis showed a significant reduction in the risk of early mortality, stroke, and atrial fibrillation among surgery patients pretreated with a statin. As they noted at the time, few studies have examined the use of statin therapy in patients undergoing cardiac surgery, and the existing published studies had reported conflicting results.

The latest meta-analysis included 11 randomized, controlled clinical trials with 984 patients undergoing on- or off-pump CABG surgery. Of these studies, six included patients treated with 20 mg or 40 mg of atorvastatin, two studies treated patients with 20 mg of simvastatin, while the remaining three studies treated patients with fluvastatin 80 mg, rosuvastatin 20 mg, and pravastatin 40 mg, respectively. The duration of preoperative statin intake ranged from the night before surgery to four weeks prior to the operation. Only three studies reinitiated statin therapy following CABG.

Among seven trials that reported short-term mortality, either in-hospital or 30-day mortality, there was no effect of preoperative statin treatment observed when compared with patients who did not receive statin therapy. Eight studies included data on the incidence of atrial fibrillation during a median follow-up of 22.8 days. Among these studies, 19% of the statin-treated patients developed atrial fibrillation compared with 35.6% of patients who did not receive the lipid-lowering drug. This translated into a 60% relative reduction in risk (odds ratio 0.40; p=0.01) and number needed to treat of seven.

In nine studies with 897 participants, there was a trend toward a short-term reduction in the risk of MI, but the between-group difference failed to achieve statistical significance. There was also a trend toward a lower risk of renal failure, but again this difference did not reach statistical significance. There was no significant effect on stroke risk. Hospital length of stay in the ICU and in the hospital was significantly reduced in the statin-treated patients, although significant heterogeneity in the studies was observed.

The researchers conclude that the empirical use of statins for all patients should wait until more evidence is collected. To date, the data include mainly CABG-treated patients, and "there is sparse evidence for a benefit of a statin therapy for high-risk patient subgroups and those undergoing other cardiac procedures (for example, valvular operations or combined procedures)." Given that many high-risk patients with multiple comorbidities are slated for CABG these days, there is a need for data on the safety and effectiveness of statins in this high-risk cohort, they write. Also, the questions of the most beneficial statin and the optimal timing of pretreatment remain unanswered.


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