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Hibino M, Verma S, Pandey AK, Bisleri G, Yanagawa B, Verma R, Puar P, Quan A, Teoh H, Yau TM, Verma A, Ha AC, Mazer CD. The impact of statins on post-discharge atrial fibrillation after cardiac surgery: Secondary analysis from a randomized trial. CJC Open 2022; 5:285-291. [PMID: 37124963 PMCID: PMC10140742 DOI: 10.1016/j.cjco.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Background Whether statins reliably reduce the risk of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery remains controversial. We sought to determine the impact of statin use on new-onset postdischarge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial. Methods We randomized 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥ 2) and no history of preoperative atrial fibrillation (AF) to 30-day continuous cardiac rhythm monitoring after discharge from cardiac surgery with a wearable, patched-based device or to usual care. The primary endpoint was the occurrence of cumulative AF and/or atrial flutter lasting for ≥ 6 minutes detected by continuous monitoring, or AF and/or atrial flutter documented by a 12-lead electrocardiogram within 30 days of randomization. Results The 260 patients (77.4%) discharged on statins were more likely to be male (P = 0.018) and to have lower CHA2DS2-VASc scores (P = 0.011). Patients treated with statins at discharge had a 2-fold lower rate of POAF than those who were not treated with statins in the entire cohort (18.4% vs 8.1%, log-rank P = 0.0076). On multivariable Cox regression including the CHA2DS2-VASc score adjustment, statin use was associated with a lower risk of POAF (hazard ratio 0.43, 95% confidence interval: 0.25-0.98, P = 0.043). Use of statins at a higher intensity was associated with lower risk of POAF, suggestive of a dose-response effect (log-rank P trend = 0.0082). Conclusions The use of statins was associated with a reduction in postdischarge POAF risk among patients undergoing cardiac surgery. The routine use of high-intensity statin to prevent subacute POAF after discharge deserves further study.
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Affiliation(s)
- Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University, School of Medicine, Atlanta, Georgia, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Dr Subodh Verma, Division of Cardiac Surgery, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8.
| | - Arjun K. Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pankaj Puar
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Terrence M. Yau
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Atul Verma
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Andrew C.T. Ha
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - C. David Mazer
- Department of Anesthesia, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Corresponding authors: Dr David Mazer, Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada.
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Statin and Postcardiac Surgery Atrial Fibrillation Prevention: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2022; 80:180-186. [PMID: 35580320 DOI: 10.1097/fjc.0000000000001294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/23/2022] [Indexed: 10/15/2022]
Abstract
ABSTRACT Postoperative atrial fibrillation (POAF) is a frequently reported postcardiac surgery complication leading to increased in-hospital and long-term mortality rates. Many randomized controlled trials (RCTs) have recently suggested using statins to protect against POAF. Therefore, we performed a systematic literature search and meta-analysis in electronic databases for eligible studies published between January 2006 and January 2022. The principal inclusion criteria were as follows: RCTs' study design, statin-naive patients, total study participants ≥50 units, and statin pretreatment started no more than 21 days before cardiac surgery. In the primary analysis, statin pretreatment reduced the incidence of POAF compared with placebo. Analyzing different molecules, atorvastatin was associated with lower incidence of POAF but rosuvastatin was not. We therefore performed a sensitivity analysis excluding RCTs affected by important risk of biases. Thus, studies whose participants were ≥199 were those eligible for the secondary analysis. No statistically significant difference between statin pretreatment and placebo (OR 0.87; 95% CI: 0.71-1.07, P = 0.18) as well as for atorvastatin (OR 0.88; 95% CI: 0.61-1.28; P = 0.48; I 2 = 84%) and rosuvastatin (OR 0.87; 95% CI: 0.68-1.12, P = 0.29) was observed. To conclude, statin pretreatment before cardiac surgery is not associated with a significant reduction in POAF occurrence.
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Zhang J, Xu S, Xu Y, Liu Y, Li Z, Zhang Y, Jin Y, Xue X, Wang H. Relation of Mitochondrial DNA Copy Number in Peripheral Blood to Postoperative Atrial Fibrillation After Isolated Off-Pump Coronary Artery Bypass Grafting. Am J Cardiol 2017; 119:473-477. [PMID: 27887690 DOI: 10.1016/j.amjcard.2016.10.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 12/31/2022]
Abstract
Oxidative stress has been considered to be an important factor contributing to postoperative atrial fibrillation (PoAF). Mitochondrial DNA (mtDNA) copy number in peripheral blood has been found to be associated with a patient's oxidative stress. Therefore, we sought to determine whether there was association between mtDNA copy number and the onset of atrial fibrillation. mtDNA copy numbers were measured using the quantitative real-time polymerase chain reaction in peripheral blood from 485 consecutive patients with sinus rhythm undergoing coronary artery bypass grafting. The blood was collected before surgery. In the cohort, the incidence of PoAF was 20.8% (101/485). The mean mtDNA copy number was significantly higher in patents with PoAF than in those with sinus rhythm (36.43 vs 16.63, p <0.001). The receiver operating characteristic analysis proved that the mtDNA copy number could predict PoAF with good sensitivity and specificity (area under the curve = 0.814, cutoff = 20.91, sensitivity = 70.3%, specificity = 80.2%, p <0.001). On multivariate logistic and Cox regression analysis, mtDNA copy number was shown to be a significant independent risk factor for PoAF (odds ratio = 10.01, p <0.001 and hazard ratio = 7.011, p = 0.004). There was a strong positive correlation between mtDNA copy number and malondialdehyde in patients with PoAF (r = 0.449, p = 0.01). In conclusion, we showed that elevated mtDNA copy number in peripheral blood is associated with PoAF. Further investigation is needed to validate mtDNA copy number as a predictive biomarker for PoAF and to explore its potential role in arrhythmogenesis.
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Affiliation(s)
- Jian Zhang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Shu Xu
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China; Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shanxi, China
| | - Yinli Xu
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Yu Liu
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Zhi Li
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Yuji Zhang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Yan Jin
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China
| | - Xiaodong Xue
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China.
| | - Huishan Wang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning, China.
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Abstract
BACKGROUND Despite substantial success in the anesthetic and surgical management of cardiac surgery, patients frequently show postoperative complications and organ dysfunctions. This is highly relevant for mid- to long-term outcomes. OBJECTIVES To evaluate cardioprotective strategies that may offer effective protection in vulnerable cardiac surgery patients. METHODS To demonstrate recent cardioprotective approaches for cardiac surgery patients, aiming to modulate the body's own protective mechanisms in cardiac surgery patients. RESULTS Both cardioplegia and hypothermia belong to the well-established protective strategies during myocardial ischemia. Volatile anesthetics have been repeatedly shown to improve the left ventricular function and reduce the extent of myocardial injury compared to a control group with intravenous anesthesia. Furthermore, patients receiving volatile anesthetics showed a significantly shortened stay in the ICU and in hospital after cardiac surgery. In contrast, numerous other protective strategies failed translation into the clinical practice. Despite the published reduction of troponin release after remote ischemic preconditioning, two recent large-scale randomized multicenter trials were unable to demonstrate a clinical benefit. CONCLUSIONS Beside the use of cardioplegia and hypothermia, the use of volatile anesthetics is well-established during cardiac surgery because of its conditioning and protective properties. Regardless of the promising results derived from experimental studies and small clinical trials, the majority of other approaches failed to translate their findings into the clinic. Therefore, systematic experimental studies are needed to identify potential confounding factors that may affect the protective effects.
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Elmarsafawi AG, Abbassi MM, Elkaffas S, Elsawy HM, Sabry NA. Efficacy of Different Perioperative Statin Regimens on Protection Against Post-Coronary Artery Bypass Grafting Major Adverse Cardiac and Cerebral Events. J Cardiothorac Vasc Anesth 2016; 30:1461-1470. [PMID: 27595528 DOI: 10.1053/j.jvca.2016.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Comparing different perioperative statin regimens for the prevention of post-coronary artery bypass grafting adverse events. DESIGN A randomized, prospective study. SETTING Cardiothoracic surgical units in a government hospital. PARTICIPANTS The study comprised 94 patients scheduled for elective, isolated on- or off- pump coronary artery bypass grafting. INTERVENTIONS Patients were assigned randomly to 1 of the following 3 treatment groups: group I (80 mg of atorvastatin/day for 2 days preoperatively), group II (40 mg of atorvastatin/day for 5-9 days preoperatively), or group III (80 mg of atorvastatin/day for 5-9 days preoperatively). The same preoperative doses were restarted postoperatively and continued for 1 month. MEASUREMENTS AND MAIN RESULTS Cardiac troponin I, creatine kinase, and C-reactive protein (CRP) levels were assayed preoperatively; at 8, 24, and 48 hours postoperatively; and at discharge. CRP levels at 24 hours (p = 0.045) and 48 hours (p = 0.009) were significantly lower in group III compared with the other 2 groups. However, troponin I levels at 8 hours (p = 0.011) and 48 hours (p = 0.025) after surgery were significantly lower in group II compared with group III. The incidence of postoperative major adverse cardiac and cerebrovascular events was assessed, and there was no significant difference among the 3 groups. CONCLUSION The 3 regimens did not result in any significant difference in outcomes, but only simple trends. The higher-dose regimen resulted in a significant reduction in the CRP level. Thus, more studies are needed to confirm the benefit of higher-dose statins for the protection from post-coronary artery bypass grafting adverse events.
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Affiliation(s)
- Aya G Elmarsafawi
- Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Cairo University, Cairo, Egypt.
| | - Maggie M Abbassi
- Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Sameh Elkaffas
- Cardiovascular Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hassan M Elsawy
- Cardiac Surgery Department, National Heart Institute, Giza, Egypt
| | - Nirmeen A Sabry
- Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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Barakat AF, Saad M, Abuzaid A, Mentias A, Mahmoud A, Elgendy IY. Perioperative Statin Therapy for Patients Undergoing Coronary Artery Bypass Grafting. Ann Thorac Surg 2016; 101:818-25. [PMID: 26794880 DOI: 10.1016/j.athoracsur.2015.09.070] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 12/13/2022]
Abstract
Coronary artery bypass grafting is associated with an intense systemic inflammatory response, which is linked to postoperative complications. Beyond lipid lowering, statins exert a constellation of beneficial actions, including an antiinflammatory role, known as pleiotropic effects. There is increasing evidence that perioperative statin therapy improves outcomes in patients undergoing coronary artery bypass grafting. Statins are underused in the coronary artery bypass grafting population, because perioperative discontinuation remains a common practice. This article provides an extensive review of the available literature on the effect of perioperative statin therapy on post–coronary artery bypass grafting outcomes and weighs the evidence for the concerns about increased incidence of statin-related adverse effects in this setting.
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