Statins as antiarrhythmics: a systematic review part I: effects on risk of atrial fibrillation

Quantitative cardiovascular magnetic resonance findings and clinical risk factors predict cardiovascular outcomes in breast cancer patients

BACKGROUND

Cardiac magnetic resonance (CMR) global longitudinal strain and circumferential strain abnormalities have been associated with left ventricular ejection fraction (LVEF) reduction and cardiotoxicity from oncologic therapy. However, few studies have evaluated the associations of strain and cardiovascular outcomes.

OBJECTIVES

To assess CMR circumferential and global longitudinal strain (GLS) correlations with cardiovascular outcomes including myocardial infarction, systolic dysfunction, diastolic dysfunction, arrhythmias and valvular disease in breast cancer patients treated with and without anthracyclines and/or trastuzumab therapy.

METHODS

Breast cancer patients with a CMR from 2013-2017 at Yale New Haven Hospital were included. Patient co-morbidities, medications, and cardiovascular outcomes were obtained from chart review. Biostatistical analyses, including Pearson correlations, competing risk regression model, and competing risk survival curves comparing the two groups were analyzed.

RESULTS

116 breast cancer with CMRs were included in our analysis to assess differences between Anthracycline/Trastuzumab (AT) (62) treated versus non anthracycline/trastuzumab (NAT) (54) treated patients in terms of imaging characteristics and outcomes. More AT patients 17 (27.4%) developed systolic heart failure compared to the NAT group 6 (10.9%), p = 0.025. Statin use was associated with a significant reduction in future arrhythmias (HR 0.416; 95% CI 0.229-0.755, p = 0.004). In a sub-group of 13 patients that underwent stress CMR, we did not find evidence of microvascular dysfunction by sub-endocardial/sub-epicardial myocardial perfusion index ratio after adjusting for ischemic heart disease.

CONCLUSIONS

In our study, CMR detected signs of subclinical cardiotoxicity such as strain abnormalities despite normal LV function and abnormal circumferential strain was associated with adverse cardiovascular outcomes such as valvular disease and systolic heart failure. Thus, CMR is an important tool during and after cancer treatment to identity and prognosticate cancer treatment-related cardiotoxicity.

High-Density Lipoprotein Cholesterol (HDL-C) Levels Independently Correlates With Cardiac Arrhythmias and Atrial Fibrillation

Objective:

Acute coronary syndrome is frequently complicated by rhythm disturbances, yet any association between high-density lipoprotein (HDL) cholesterol levels and arrhythmias in the setting of non-ST-segment elevation myocardial infarction (non-STEMI) is uncertain. The goal of this study was to evaluate any association between HDL-cholesterol levels and arrhythmias in the setting of non-STEMI.

Methods:

Retrospective data from Phoenix Veterans Affair Medical Center records were utilized for our study. A total of 6881 patients were found who presented during 2000 to 2003 with non-STEMI with available fasting lipid panels collected within the first 24 hours of admission. Patients were followed for the development of rhythm disturbances up to 6 years after initial presentation, with a mean follow up of 1269 days.

Results:

We found that high triglycerides/HDL and low-density lipid/HDL ratios were predictive of arrhythmias. However, low HDL levels had strongest association with highest odds ratio (OR) for development of arrhythmias (for HDL <31 mg/dL, OR = 3.72, 95% confidence interval [CI] = 2.55-5.44, P < .05) in patients with diabetes and (for HDL < 31 mg/dL, OR = 3.69, 95% CI = 2.85-4.71, P < .05) in patients without diabetes. Using multivariate analysis adjusting for comorbidities, low HDL level remained independently associated with arrhythmias.

Conclusions:

Patients with low HDL levels during hospitalization with non-STEMI have a greater risk of developing cardiac rhythm disturbances independent of other risk factors. These data suggest a possible protective role of HDL in preventing arrhythmias in the setting of acute coronary syndrome.

Impact of statin therapy on all-cause mortality and ICD interventions in heart failure patients - a systematic review

OBJECTIVES

Implantable cardioverter defibrillators (ICDs) have a unique role for the primary and secondary prevention of sudden cardiac death (SCD). The aim of our systematic review is to present the existing data about the impact of statins on all-cause mortality and ICD interventions in heart failure (HF) patients who had an ICD implanted either for primary or for secondary prevention of SCD.

METHODS AND RESULTS

We searched PubMed database and the reference list of the relevant studies for retrieving studies evaluating the effect of statins on all-cause mortality and ICD interventions in HF patients. We finally included 17 relevant studies in our systematic review. Of them, nine studies included data about the impact of statins on all-cause mortality, eight studies about the impact of statins on appropriate ICD interventions and three studies about the impact of statins on inappropriate ICD interventions in HF patients. These data showed that statins seem to have a beneficial role in the reduction of all-cause mortality and ICD interventions in HF patients.

CONCLUSIONS

Statins seem to have a beneficial role in the reduction of all-cause mortality and ICD interventions in HF patients. However, further research about pleiotropic effects of statins is needed as well randomized control trials to elucidate the exact role of statin therapy in ICD outcomes.

Effects of Atorvastatin on Serum High-Sensitive C-Reactive Protein and Total Cholesterol Levels in Asian Patients With Atrial Fibrillation

Elevated serum levels of high-sensitive C-reactive protein (hs-CRP) and total cholesterol (TC) correlate with atherosclerotic vascular disease and increased frequency of vascular events. In this study, we investigated the effect of atorvastatin treatment on serum hs-CRP and TC levels, and the recurrence rate of atrial fibrillation (AF) in patients. Furthermore, a meta-analysis was performed to confirm the findings in this study. A total of 105 patients with AF were recruited to this study, including 55 patients with AF who were treated with amiodarone and atorvastatin (the treatment group) and 50 patients with AF who were treated with only amiodarone (the control group). Patients were treated for 12 months and followed up regularly for 1 year. Serum hs-CRP and TC levels in patients before and after treatment were recorded, and AF recurrence rate at 3, 6, and 12 months of treatment was obtained. Statistical analyses were performed with R 3.1.0 software and STATA 12.0 software. For patients in both treatment and control groups, serum hs-CRP and TC levels were high before the treatments began (both P < 0.05). However, after 12 months of treatment, serum hs-CRP and TC levels in the treatment group was dramatically reduced compared with the control group (hs-CRP: 3.63 ± 2.14 mg/L vs. 2.75 ± 1.89 mg/L, t = 2.24, P = 0.027; TC: 4.66 ± 1.13 mmol/L vs. 4.20 ± 1.06 mmol/L, t = 2.15, P = 0.034). After 12 months of treatment, the AF recurrence rate in the treatment group was significantly lower than the control group (16.4% vs. 34.0%; χ = 4.37; P = 0.037). In addition, 13 studies were selected for meta-analysis. Pooled results of the meta-analysis showed that serum hs-CRP and TC levels decreased significantly in the treatment group compared with the case group [hs-CRP: SMD = 0.95, 95% confidence interval (CI) = 0.62-1.29, and P < 0.001; TC: SMD = 1.39, 95% CI = 0.65-2.13, and P < 0.001]. Our study presents compelling evidence that atorvastatin is highly effective in reducing serum hs-CRP and TC levels and lowering the recurrence rate of AF.

The efficacy and tolerability of commonly used agents to prevent recurrence of atrial fibrillation after successful cardioversion

A number of therapeutic strategies exist for the restoration and maintenance of sinus rhythm in patients presenting with atrial fibrillation. The acute success rate with electrical cardioversion is high. However, many patients relapse into atrial fibrillation. A major challenge faced by those who care for patients with atrial fibrillation is the long-term maintenance of sinus rhythm whilst avoiding treatment-related adverse effects. This review examines the efficacy and tolerability of conventional anti-arrhythmic drugs for the secondary prevention of atrial fibrillation in the post-cardioversion period.

Benefits & risks of statin therapy for primary prevention of cardiovascular disease in Asian Indians - a population with the highest risk of premature coronary artery disease & diabetes

Several reviews and meta-analyses have demonstrated the incontrovertible benefits of statin therapy in patients with cardiovascular disease (CVD). But the role for statins in primary prevention remained unclear. The updated 2013 Cochrane review has put to rest all lingering doubts about the overwhelming benefits of long-term statin therapy in primary prevention by conclusively demonstrating highly significant reductions in all-cause mortality, major adverse cardiovascular events (MACE) and the need for coronary artery revascularization procedures (CARPs). More importantly, these benefits of statin therapy are similar at all levels of CVD risk, including subjects at low (<1% per year) risk of a MACE. In addition to preventing myocardial infarction (MI), stroke, and death, primary prevention with statins is also highly effective in delaying and avoiding expensive CARPs such as angioplasties, stents, and bypass surgeries. There is no evidence of any serious harm or threat to life caused by statin therapy, though several adverse effects that affect the quality of life, especially diabetes mellitus (DM) have been reported. Asian Indians have the highest risk of premature coronary artery disease (CAD) and diabetes. When compared with Whites, Asian Indians have double the risk of CAD and triple the risk of DM, when adjusted for traditional risk factors for these diseases. Available evidence supports the use of statin therapy for primary prevention in Asian Indians at a younger age and with lower targets for low-density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein (non-HDL-C), than those currently recommended for Americans and Europeans. Early and aggressive statin therapy offers the greatest potential for reducing the continuing epidemic of CAD among Indians.

Statins in non-ischaemic cardiomyopathy: an update on our current clinical and pathophysiological understanding

Statins are a cornerstone in reducing cardiovascular events. Studies show that statins are beneficial even in patients with normal or low cholesterol levels, indicating pleiotropic mechanisms of therapeutic benefit apart from their antihyperlipidemic effect. Non-randomised, observational and retrospective studies suggest that statins are associated with better outcomes in patients with heart failure (HF) of both ischaemic and non-ischaemic aetiologies. While cholesterol reduction and plaque stabilisation likely play a role in reducing cardiovascular events in ischaemic HF patients, the mechanisms underlying the benefit in non-ischaemic HF patients is less clear. This review suggests the pleiotropic effects of statin therapy can beneficially alter the pathophysiological mechanisms underlying the clinical benefit observed in non-ischaemic HF patients.

n-3 polyunsaturated fatty acids for the prevention of arrhythmia recurrence after electrical cardioversion of chronic persistent atrial fibrillation: a randomized, double-blind, multicentre study

AIMS

Persistent atrial fibrillation (AF) often recurs after direct current electrical cardioversion (ECV). As several experimental and clinical studies suggest that n-3 polyunsaturated fatty acids (PUFAs) may have antiarrhythmic properties even at the atrial level, we aimed to evaluate whether oral supplementation with PUFAs, in addition to conventional antiarrhythmic drugs, could reduce the recurrence rate of the arrhythmia after ECV of persistent AF.

METHODS AND RESULTS

Two hundred and four patients (mean age 69.3 years, 33% females) with persistent AF were randomly assigned to receive 3 g/day of PUFAs until ECV and 2 g/day thereafter (104 patients) or placebo (100 patients) for 6 months, beginning at least 1 week before ECV. Selection of conventional antiarrhythmic prophylaxis was left to local medical advice. The cardiac rhythm was assessed by both trans-telephonic monitoring and clinical visits. Primary end-point was the recurrence rate of AF. Sinus rhythm was restored, either spontaneously or after ECV, in 187 patients (91.7%); 95 patients (91.4%) on PUFAs and 92 patients (92.0%) on placebo (P=not significant). AF relapsed in 56 (58.9%) of the PUFAs patients and in 47 (51.1%) of the placebo patients (P=0.28). The mean time to AF recurrence was 83±8 days in the PUFAs group and 106±9 days in the placebo group (P=0.29).

CONCLUSION

Our results do not support the hypothesis that, in patients undergoing ECV of chronic persistent AF, supplementation with PUFAs in addition to the usual antiarrhythmic treatment reduces recurrent AF.

Progress in perioperative medicine: focus on statins

Beyond cholesterol reduction, statins have multiple beneficial influences on vascular endothelial function, atherosclerotic plaque stability, inflammation, and thrombosis. These favorable pleiotropic effects may be the basis for their perioperative risk reduction in cardiothoracic and vascular procedures. The published evidence suggests that statins offer significant outcome benefits throughout perioperative practice. Because statin therapy significantly reduces the perioperative risk for patients undergoing cardiovascular procedures, they already are recommended in published guidelines. Beyond cardiac risk reduction, statin therapy also may protect the brain and the kidney in the perioperative setting, both in cardiac and vascular surgery. The pleiotropic effects of statins also appear to have therapeutic roles in the progression of valve disease, sepsis, and venous thrombosis. Further trials are required to provide data to drive their safe and comprehensive perioperative application for optimal patient outcome both in the short term and the long term. Because there are multiple randomized trials currently in progress throughout perioperative medicine, it is very likely that the indications for statins will be expanded significantly.