Atorvastatin given prior to electrical cardioversion does not affect the recurrence of atrial fibrillation in patients with persistent atrial fibrillation who are on antiarrhythmic therapy

The Efficacy of Anti-inflammatory Agents in the Prevention of Atrial Fibrillation Recurrences

Several studies have indicated an association between inflammation and the recurrence of Atrial Fibrillation (AF), especially after ablation, which is a therapeutic option leading to local inflammation. On the other hand, each AF can lead to another AF, as a general rule. Thus, preventing recurrences of AF is extremely important for patient outcomes. In this paper, we attempted to review the effect of medicinal agents with anti-inflammatory properties on the prevention of AF recurrence. There are several randomized controlled trials (RCTs) and meta-analyses on the prevention of AF recurrence using agents with anti-inflammatory properties, which include steroids, colchicine, statins, and n-3 fatty acids (n-3 FA). Clinical trials evaluating the efficacy of anti-inflammatory drugs in preventing the recurrence of AF led to inconsistent results for corticosteroids, statins and n-3 FAs. These results may be related to the fact that inflammation is not the only factor responsible for triggering recurrences of AF. For example, the presence of structural, mechanical and electrical remodeling could potentially be the most important factors that trigger recurrences of AF but these factors have not been addressed in most of the reported studies. Therefore, future clinical trials are needed to compare the efficacy of anti-inflammatory drugs in AF patients with, or without other factors. For colchicine, a potent anti-inflammatory drug, there are limited studies. However, all the studies investigating colchicine in the context of AF were consistent and promising, especially when colchicine was used on a short-term basis following ablation in patients with paroxysmal AF. Therefore, colchicine could be a promising candidate for further clinical studies involving recurrent AF.

The Pleiotropic Effects of Statins - From Coronary Artery Disease and Stroke to Atrial Fibrillation and Ventricular Tachyarrhythmia

Statins, 3-hydroxy-methylglutaryl coenzyme A reductase inhibitors, have been used for decades for the prevention of coronary artery disease and stroke. They act primarily by lowering serum cholesterol through the inhibition of cholesterol synthesis in the liver, which results in the upregulation of low-density lipoprotein receptors in the liver. This results in the removal of low-density lipoproteincholesterol. Studies have suggested that statins may demonstrate additional effects that are independent of their effects on low-density lipoprotein-cholesterol. These have been termed "pleiotropic" effects. Pleiotropic effects may be due to the inhibition of isoprenoid intermediates by statins. Isoprenoid inhibition has effects on the small guanosine triphosphate binding proteins Rac and Rho which in turn effects nicotinamide adenine dinucleotide phosphate oxidases. Therefore, there are changes in endothelial nitric oxide synthase expression, atherosclerotic plaque stability, pro-inflammatory cytokines and reactive oxygen species production, platelet reactivity, and cardiac fibrosis and hypetrophy development. Recently, statins have been compared to the ezetimibe and the recently published outcomes data on the proprotein convertase subtilisin kexin type 9 inhibitors has allowed for a reexamination of statin pleiotropy. As a result of these diverse effects, it has been suggested that statins also have anti-arrhythmic effects. This review focuses on the mechanisms of statin pleiotropy and discusses evidence from the statin clinical trials as well as examining the possible anti-arrhythmic effects atrial fibrillation and ventricular tachyarrhythmias.

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.

Atorvastatin Treatment for Atrial Fibrillation Reduces Serum High-Sensitivity C-Reactive Protein Levels

We investigated whether serum hs-CRP levels predict the efficacy of atrial fibrillation (AF) treated with atorvastatin. Bibliographic databases were exhaustively searched for studies relevant to the research topic. Newcastle-Ottawa Scale (NOS) criteria, combined with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), were applied for study quality assessment. Our meta-analysis identified seven cohort studies (2006~2013), providing information on the change in serum hs-CRP levels in AF patients receiving atorvastatin therapy. After atorvastatin treatment, hs-CRP level in AF patients decreased significantly (SMD = 1.02, 95% CI: 0.58–1.47, P < 0.001). Subgroup analysis by country and hs-CRP detection methods suggested a negative relationship between atorvastatin treatment and hs-CRP levels among Chinese AF patients (SMD = 1.34, 95% CI: 1.00–1.69, P < 0.001) and by using ELISA method (SMD = 1.11, 95% CI: 0.51–1.71, P < 0.001), but not among Turkish population and using INA method (all P > 0.05). Egger's test showed no publication bias (P = 0.450). hs-CRP was clearly lowered in AF patients treated with atorvastatin, which may be helpful in the choice of statin agents for AF treatment. However, longer follow-ups are necessary to assess the clinical value of lowering hs-CRP in the clinical setting of AF treatment outcomes.

Effect of Atorvastatin on Serum Levels of Total Cholesterol and High-Sensitivity C-reactive Protein in High-Risk Patients with Atrial Fibrillation in Asia

PURPOSE

The aim of this meta-analysis was to investigate the effects of atorvastatin on serum levels of high-sensitivity C-reactive protein (hs-CRP) and total cholesterol in atrial fibrillation (AF) patients in Asia.

METHODS

By searching English and Chinese language-based electronic databases (ie, PubMed, EBSCO, Ovid, SpringerLink, Wiley, Web of Science, Wanfang database, China National Knowledge Infrastructure, and VIP database), we identified 13 studies relevant to our topic of interest. Data were collected from the 13 studies and analyzed with Comprehensive Meta-Analysis software (version 2.0, Biostat Inc., Englewood, New Jersey).

FINDINGS

Initially, our database searches retrieved 356 studies (45 in English, 311 in Chinese). Thirteen studies were selected for the meta-analysis following stringent criteria. The data included 1239 patients with AF, of whom 634 were treated with atorvastatin and included in the treatment group, and 605 patients were treated with conventional treatment and included in the control group. The results of our meta-analysis suggested that the serum levels of hs-CRP (mg/L) and total cholesterol (mmol/L) in the treatment group were significantly lower than those of the control group (hs-CRP: standardized mean difference = 0.962; 95% CI, 0.629-1.295, P < 0.001; total cholesterol: standardized mean difference = 1.400; 95% CI, 0.653-2.146, P < 0.001).

IMPLICATIONS

The findings of this study suggest that atorvastatin may be very effective in decreasing serum levels of hs-CRP and total cholesterol to prevent cardiovascular events.

Atrial electromechanical delay is impaired in patients with psoriasis

OBJECTIVE

In this study, we aimed to investigate atrial electromechanical delay (EMD) in patients with psoriasis.

SUBJECTS AND METHODS

A total of 43 patients with psoriasis (26 mild-moderate, 17 severe) and 17 healthy control subjects were enrolled. Patients with psoriasis were divided into two groups: the mild-moderate group and the severe group according to their psoriasis area severity index (PASI) scores. Atrial EMD was measured from the lateral mitral annulus and called 'PA lateral', from the septal mitral annulus, called 'PA septal', and from the right ventricle tricuspid annulus, called 'PA tricuspid'. Atrial EMD was defined as the time interval from the onset of atrial electrical activity (P wave on surface ECG) to the beginning of mechanical atrial contraction (late diastolic A wave). All three groups were compared with each other, and correlation analysis was performed to investigate the relationship between the PASI score and interatrial EMD.

RESULTS

PA lateral was significantly higher in both the mild-moderate psoriasis group and the severe psoriasis group compared to controls (69 ± 12 and 78 ± 13 vs. 60 ± 6 ms; p = 0.001). Also, PA septal (63 ± 11 vs. 53 ± 6 ms; p = 0.005, post hoc analysis) and PA tricuspid (49 ± 7 vs. 41 ± 5 ms; p = 0.009, post hoc analysis) were significantly higher in the severe psoriasis group than in the control group. Correlation analysis revealed that the PASI score was well correlated with PA lateral (r = 0.520, p < 0.001), PA septum (r = 0.460, p = 0.002), interatrial EMD (r = 0.371, p = 0.014) and intra-atrial EMD (r = 0.393, p = 0.009).

CONCLUSION

Atrial EMD was prolonged in patients with psoriasis. The measurement of atrial EMD might be used to determine the risk of development of AF in patients with psoriasis.

Statin therapy decreased the recurrence frequency of atrial fibrillation after electrical cardioversion: a meta-analysis

Background

It is unclear whether statin agents provide clinical benefit in preventing the relapse of atrial fibrillation (AF) after electrical cardioversion (EC). The purpose of this study was to assess the effect of statin agents on the recurrence of AF after EC by conducting a meta-analysis of randomized controlled trials (RCTs).

Material/Methods

We conducted a systematic literature search of Medline, EMBASE, ISI Web of Science, and Cochrane databases. RCTs comparing clinical endpoint of the recurrence of AF associated with statin administration vs. no statin treatment (placebo or conventional medical therapy) in patients with AF after EC were eligible. Combined results are presented as risk ratios (RRs) with 95% confidence intervals (CIs).

Results

A total of 5 trials with 524 patients were available for analysis. The pooling analysis showed that statin agents significantly reduced the recurrence of AF after EC compared with no statin treatment (RR=0.76, 95% CI 0.63–0.92; p=0.004; I²=44%). The beneficial effect was shown both in AF subjects receiving atorvastatin or rosuvastatin treatment (atorvastatin 80 mg: RR=0.82, p=0.05; atorvastatin 10 mg: RR=0.27, p=0.03; rosuvastatin: RR=0.38, p=0.04) and in younger patients (<65 years; RR=0.58, p=0.0005). Furthermore, the benefit of statin agents on preventing AF recurrence after EC was demonstrated within 3-month follow-up (p=0.03), and the clinical benefit seemed likely to remain until no less than 12 months after EC (p=0.05).

Conclusions

Based on the currently available data, administration of statin agents, especially atorvastatin or rosuvastatin, is beneficial in lowering the frequency of AF recurrence after EC.

The preventive effect of atorvastatin on atrial fibrillation: a meta-analysis of randomized controlled trials

Background

A number of clinical and experimental studies have investigated the effect of atorvastatin on atrial fibrillation (AF), but the results are equivocal. This meta-analysis was performed to evaluate whether atorvastatin can reduce the risk of AF in different populations.

Methods

We searched PubMed, EMBASE and the Cochrane Database for all published studies that examined the effect of atorvastatin therapy on AF up to April 2014. A random effects model was used when there was substantial heterogeneity and a fixed effects model when there was negligible heterogeneity.

Results

Eighteen published studies including 9952 patients with sinus rhythm were identified for inclusion in the analysis. Ten studies investigated primary prevention of AF by atorvastatin in patients without AF, seven studies investigated secondary prevention of atorvastatin in patients with AF, and one study investigated mixed populations of patients. Overall, atorvastatin was associated with a decreased risk of AF (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.36–0.70, P < 0.0001). However, subgroup analyses showed that in the primary prevention subgroup (OR 0.55, 95% CI 0.38–0.81, P = 0.002), atorvastatin reduced the risk of new-onset AF in patients after coronary surgery (OR 0.44, 95% CI 0.29–0.68, P = 0.0002), but had no beneficial effect in patients without coronary surgery (OR 0.97, 95% CI 0.59–1.58, P = 0.89); in the secondary prevention subgroup, atorvastatin had no beneficial effect on AF recurrence in patients with electrical cardioversion (EC) (OR 0.57, 95% CI 0.25–1.32, P = 0.19) or without EC (OR 0.38, 95% CI 0.14–1.06, P = 0.06).

Conclusions

This meta-analysis suggests that atorvastatin has an overall protective effect against AF. However, this preventive effect was not seen in all types of AF. Atorvastatin was significantly associated with a decreased risk of new-onset AF in patients after coronary surgery. Moreover, atorvastatin did not prove to exert a significant protective effect against the AF recurrences in both patients who had experienced sinus rhythm restoration by means of EC and those who had obtained cardioversion by means of drug therapy. Thus, further prospective studies are warranted.

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.

Impact of duration and dosage of statin treatment and epicardial fat thickness on the recurrence of atrial fibrillation after electrical cardioversion

The purpose of this study was to investigate the time-dependent effect of statin treatment and echocardiographic epicardial fat thickness (EFT) on the maintenance of sinus rhythm (SR) in atrial fibrillation (AF) patients after electrical cardioversion (EC). One hundred sixty-three AF patients without previous statin treatment who underwent EC were consecutively enrolled. The maintenance rate of SR after EC (1, 3, 6, and 12 months) as documented by electrocardiogram and EFT were compared between patients with statin treatment (statin group, n = 63) and those without (no statin group, n = 100). There was no significant difference in the maintenance rate of SR between the groups soon after EC (statin group; 85.7 % vs. no statin; 84.8%, p = 0.535), after 1 month (71.0 vs. 59.1%, p = 0.091), and after 3 months (63.2 vs. 50.0%, p = 0.086). However, the maintenance rate of SR was significantly higher in the statin group compared to no statin group (61.8 vs. 42.9%, p = 0.024) after 6 months, and this significant difference persisted up to 12 months of follow up (60.1 vs. 36.4%, p = 0.001). Patients with recurrence showed higher baseline EFT (7.4 ± 2.7 vs. 8.5 ± 3.0 mm, p = 0.014). Multivariate linear regression analysis indicated that EFT, left atrial diameter, high-density lipoprotein cholesterol, statin treatment, and dose were the significant contributors to the maintenance of SR for all periods after EC. Statin treatment and low EFT were associated with a higher maintenance rate of SR in AF patients after EC. Significant benefit of statin was realized 6 months after EC, and this benefit was shown to be maintained over time.

The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation

OBJECTIVE

To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE).

MATERIALS AND METHODS

The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study.

RESULTS

A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF.

CONCLUSION

A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.

Upstream therapy with statin and recurrence of atrial fibrillation after electrical cardioversion. Review of the literature and meta-analysis

Background

Atrial fibrillation (AF) is the most common sustained arrhythmia observed in clinical practice. Electrical cardioversion (EC) is commonly used to restore and maintain sinus rhythm but it is characterized by high rate of recurrences. Several trials analyzed the effects of statins to reduce the recurrences in AF with contradictory results.

Methods

We performed a meta-analysis of the interventional trials with statins in patients with persistent AF to evaluate recurrences after EC. Only randomized controlled trials were included in the analysis. Data sources included: Medline, ISI Web of Science, SCOPUS and Cochrane database (up to June 2012). Data extraction was performed by three authors. Study-specific odds ratios (ORs) were combined using fixed-effects model.

Results

Six studies with 515 patients were included in the analysis. Statins used in the selected trials were: atorvastatin (at dosages ranging from 10 to 80 mg/day), pravastatin (40 mg/day) and rosuvastatin (20 mg/day). AF recurrence after EC occurred in 108/258 (41.8%) of patients treated with statins and in 132/257 (51.3%) patients not on treatment with statins. Compared with control, recurrences were significantly reduced with statin treatment (O.R.: 0.662; 95% C.I., 0.45-0.96; p=0.03); statin treatment was associated with an absolute risk reduction of 0.095 and a number needed to treat of 11.

Conclusions

This review suggests that statin therapy was significantly associated with a decreased risk of recurrence in patients with persistent AF after EC.