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Ann Thorac Surg 2009;87:1853-1858. doi:10.1016/j.athoracsur.2009.03.041
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Effects of Preoperative Statin Treatment on the Incidence of Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting

Antonio Miceli, MDa, Carlo Fino, MDa, Brenno Fiorani, MDb, Mark Yeatman, FRCSa, Pradeep Narayan, FRCSa, Gianni D. Angelini, FRCSa, Massimo Caputo, MDa,*

a Bristol Heart Institute, Bristol University, Bristol, United Kingdom
b Cardiac Surgery Department, S. Andrea Hospital, University of Rome "La Sapienza," Rome, Italy

Accepted for publication March 17, 2009.

* Address correspondence to Dr Caputo, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, United Kingdom (Email: m.caputo{at}bristol.ac.uk).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Postoperative atrial fibrillation is still a common complication in patients undergoing coronary artery bypass grafting. The aim of this study was to evaluate the effect of preoperative statin therapy on new onset of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting.

Methods: Of 8,946 patients undergoing isolated coronary artery bypass grafting at the Bristol Heart Institute from April 1996 to September 2006, 6,321 (70.6%) received preoperative statins. Of these, 2,152 patients (statin group) were matched to a control group (no statin) by propensity score analysis.

Results: Preoperative characteristics, number of distal anastomoses, and the use of off -pump procedures were similar in both groups. Hospital mortality was 1.3% (56 patients) with no difference between the two groups. Postoperative atrial fibrillation was significantly higher in the statin compared with the no statin group (411, 19.5%, versus 336; 15.8% respectively; p = 0.002). In a multivariate regression analysis, age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.05), pulmonary disease (OR, 1.42; 95% CI, 1.12–1.82), history of paroxysmal atrial fibrillation (OR, 3; 95% CI, 2.13 to 4.19), preoperative angiotensin-converting enzyme inhibitor therapy (OR, 1.26; 95% CI, 1.07 to 1.49), ejection fraction less than 0.30 (OR, 1.71; 95% CI, 1.22 to 2.38), emergency operations (OR, 4.5; 95% CI, 2 to 10.12), and preoperative statin treatment (OR, 1.31; 95% CI, 1.11 to 1.55) were all independent predictors of postoperative atrial fibrillation.

Conclusions: Preoperative statin is associated with a significantly higher incidence of postoperative atrial fibrillation compared with no statin treatment in patients undergoing isolated coronary artery bypass grafting.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) in 25% to 40% of patients, depending on definitions and methods of detection [1]. It is associated with an increased risk of mortality, postoperative thromboembolic events and stroke, and hemodynamic compromise, and requires additional treatment, increasing hospital stay and costs [2, 3]. The pathogenesis of POAF is attributable to a combination of predisposing, intraoperative, and postoperative factors, which in the presence of some triggers (atrial premature contractions, imbalance of autonomic nervous system, electrolyte imbalance) may induce this arrhythmia [4]. Moreover, increasing evidences show that inflammation might play an important role in the pathogenesis of POAF [5–7].

It has been shown that statin therapy, in addition to its antiatherosclerotic effects, may have antioxidant [8] and antiinflammatory properties [9, 10] and therefore a potential beneficial effect against POAF [11–14]. Patti and associates [11], in a small prospective randomized trial, have shown that the use of statin preoperatively reduces the incidence of POAF by 61% in patients undergoing CABG. Nevertheless, other studies have failed to demonstrate an antiarrhythmic statin effect after cardiac surgery [15–17]. The aim of the present study, therefore, was to evaluate the effect of preoperative statin therapy on new onset of POAF in a large cohort of patients undergoing CABG.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Selection and Data Collection
The study was approved by the clinical audit committee of the University Hospital Bristol National health Service Foundation Trust to meet ethical and legal requirements, and individual consent was waived. This was a retrospective, observational, cohort study of prospectively collected data from consecutive patients who underwent isolated CABG at the Bristol Heart Institute between April 1996 and September 2006. The data collection form is entered in a database (Patient Analysis & Tracking System; Dendrite Clinical Systems, London, UK) and includes five sections that are filled in consecutively by anesthetists, surgeons, and intensive care unit, high-dependency unit, and ward nurses. The resulting base sample contained detailed clinical information about 9,366 patients. Patients were excluded if statin use was unknown or if they were in chronic atrial fibrillation. The final sample size was 8,946 patients, of which 6,321 (70.6%) received preoperative statins. Patients were divided into two groups: those who received preoperative statin therapy and those who did not. The primary end point was incidence of in-hospital POAF, defined by the documentation of atrial fibrillation of any duration at any time in the postoperative period on the basis of a rhythm strip or 12-lead electrocardiogram. Preoperative use of statin was defined as administration within 24 hours before surgery. The secondary outcomes were in-hospital mortality and postoperative myocardial infarction (MI), stroke, and renal dysfunction. In-hospital death was defined as any death occurring during the same hospital admission for surgery. The diagnosis of postoperative MI was based on the presence of Q waves longer than 0.04 ms or a reduction in R waves of greater than 25% in at least two contiguous leads on electrocardiogram. A diagnosis of stroke was made if there was evidence of new neurologic deficit with morphologic substrate confirmed by computer tomography or nuclear magnetic resonance imaging. Renal dysfunction was defined as a serum creatinine level greater than 200 µmol/L plus an increase of at least 1.5 times in preoperative baseline concentrations. To reduce the effect of treatment selection bias and potential confounding in this observational study, we used a propensity score–matching analysis to evaluate the pure effect of preoperative treatment of statins on end points [18].

Anesthetic, Surgical Technique, and Postoperative Management
Anesthetic and surgical techniques were standardized for all patients and have been reported previously [19, 20]. At the end of surgery, patients were transferred to the intensive care unit and managed according to the unit protocol [19, 20]. During the first 72 hours after surgery, the heart rate and rhythm were continuously monitored and displayed on a screen with an automated arrhythmia detector (Solar 8000 Patient Monitor; Marquette Medic Systems, Milwaukee, WI). Twelve-lead electrocardiographic recordings were performed preoperatively, 2 hours postoperatively, and then daily thereafter until discharge. Furthermore, clinical assessment of heart rhythm was done every 6 hours until discharge. Amiodarone, either orally or intravenously administered, was the standard pharmacologic treatment for POAF. Patients without successful rhythm cardioversion and with persistent atrial fibrillation were given warfarin with the aim of achieving an international normalized ratio between 2.0 and 3.0 before discharge, planning an electric cardioversion within 30 days.

Statistical Analysis
Continuos data with normal distribution were expressed as mean ± standard deviation, and categorical data as percentages. The Kolmogorov–Smirnov test was used to check for normality of data in the two groups before further analysis. Unpaired Student's t test was used to compare continuous variables, and categorical data were analyzed using the {chi}2 test. Because statin use was not randomly assigned in this patient population, potential confounding and selection biases were accounted for by developing a propensity score for statin treatment [18].

The propensity score was the probability that a patient would receive statin treatment and was computed using a logistic regression modeling including the covariates, which are listed in Table 1. A propensity score value close to 0 means a higher probability of going into the statin group, and a value close to 1 means a higher probability of going into the other group. Finally, each patient who received statins was matched to 1 patient who did not, resulting in successful matching of 2,152 patients. A nonparsimonious logistic regression analysis was performed to identify independent risk factors for POAF. The fit of the model was assessed using the Hosmer-Lemeshow goodness-of-fit test. Results are reported as percentages and odds ratios (OR) with 95% confidence intervals (CI).


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  		Table 1 Baseline Characteristics
 
A probability value of 0.05 or less was considered statistically significant. All statistical analysis was performed with SPSS 13.0 (SPSS Inc, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Of 8,946 patients undergoing isolated CABG surgery, 6,321 (70.6%) received preoperative statins and 2,175 (29.4%, control group) did not. Baseline characteristics of the study population are shown in Table 1. Compared with the control group, the patients receiving statins had a bigger body surface area, a higher prevalence of hypertension, and a history of MI, angiotensin-converting enzyme (ACE) inhibitor use, or left main stenosis. Patients taking statins were also more likely to have a better ejection fraction, Canadian Cardiovascular Society (CCS) functional class, New York Heart Association (NYHA) functional class, and renal function than those not receiving statins. Finally, the prevalence of off-pump procedure was higher in the statin group whereas the number of anastomoses performed was lower than the control group.

After propensity-score matching was performed for the entire population, there were 2,152 matched pairs of patients (Table 2). In the matched cohorts, there was no longer any significant difference between the statin and the control group for any covariate. In this population, overall in-hospital mortality was 1.3% (56 patients) with no difference between the two groups. Median intensive care unit stay was 1 day (interquartile range, 1 to 1). Postoperative atrial fibrillation was significantly higher in the statin users compared with the nonusers (411, 19.5%, versus 336, 15.8%, respectively; OR, 1.28; 95% CI, 1.1 to 1.52; p = 0.002). No difference was found in terms of postoperative MI, renal dysfunction, and inotropic drugs (Table 3).


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  		Table 2 Baseline Variables in Propensity-Matched Cohort
 

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  		Table 3 Main Clinical Outcomes
 
The patients receiving statins had a significantly lower incidence of stroke events (8, 0.4%, versus 25, 1.2%; OR, 0.36; 95% CI, 0.14 to 0.71; p = 0.006) than those not receiving statins. In a logistic multivariate analysis, age (OR, 1.04; 95% CI, 1.02 to 1.05), pulmonary disease (OR, 1.42; 95% CI, 1.12 to 1.82), history of paroxysmal atrial fibrillation (OR, 3; 95% CI, 2.13 to 4.19), preoperative ACE inhibitor therapy (OR, 1.26; 95% CI, 1.07 to 1.49), ejection fraction less than 0.30 (OR, 1.71; 95% CI, 1.22 to 2.38), emergency operations (OR, 4.5; 95% CI, 2 to 10.12), and preoperative statin treatment (OR, 1.31; 95% CI, 1.11 to 1.55) were independent predictors of POAF (Table 4).


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  		Table 4 Multivariate Analysis of Postoperative Atrial Fibrillation in the Propensity-Matched Cohort
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The aim of the present study was to evaluate the association between preoperative use of statins and POAF in a large propensity score–matched group of patients who underwent isolated CABG. Preoperative statin therapy was associated with a significantly higher incidence of POAF compared with no statin treatment. When we analyzed the independent predictors of POAF using a multivariate logistic regression among the matched population, preoperative statin treatment conferred a 31% increase in risk of POAF. Other potential risk factors were advanced age, chronic obstructive pulmonary disease, previous history of paroxysmal atrial fibrillation, poor ejection fraction, and emergency operation. Interestingly, the use of ACE inhibitors before CABG was an additional risk factor of POAF. This demonstrates a potential arrhythmic effect of statins.

Atrial fibrillation is the most common complication occurring after heart surgery, and it is associated with a higher risk of mortality and morbidity. Despite the advance in cardiac anesthesia, myocardial protection, and surgical techniques, its incidence has increased continuously during the past years as the result of aging of the surgical population. In addition, risk factors such as hypertension, diabetes, left atrial enlargement diastolic dysfunction, surgical atrial injury, atrial ischemia, venous cannulation, volume overload, hypotension, imbalance of autonomic nervous system, or electrolyte imbalance may all contribute to the development of POAF through a dispersion of atrial refractoriness and multiple reentry wave [4]. Moreover, inflammation and oxidative stress might be involved in the development, recurrence, and persistence of atrial fibrillation [5]. It has been shown that statin therapy, in addition to its antiatherosclerotic effects, may have antioxidant [8] and antiinflammatory properties [9, 10]. ARMYDA-3, the first randomized, controlled trial, demonstrated that atorvastatin reduced the risk of POAF by 61%, with an incidence of 35% in the statin group versus 57% in the placebo group [11]. However, the study was conducted on a relatively small number of patients, and the control group, although not statistically significant, was older, more likely to have left atrial enlargement, chronic obstructive pulmonary disease, or valve disease as well as less β-blocker use. These well-known risk factors could explain the higher POAF rate in the control group than expected from the literature [1–3]. Several observational studies reported a potential beneficial effect against POAF as well [12–14, 21]. The limitations of these studies were still the small sample size of patients. Kourlious and coworkers [21] in a univariate analysis showed an absolute risk reduction of 11.2 %, but only 31 patients with POAF did not take statins and statin users were more likely to be taking β-blockers and to receive aortic valve replacement. Marin and colleagues [12] reported that of 234 patients undergoing CABG, 66 patients experienced POAF and only 25 patients were not receiving statin treatment. Finally, of 38 patients who had POAF after surgery, Ozaydin and associates [14] found an 8.6% reduction of POAF in patients taking statins. Conversely, two studies with a bigger sample size failed to show a significant difference in terms of POAF [15, 16]. A recent meta-analysis concluded that preoperative statin therapy resulted in a 4.3% absolute risk reduction in POAF and a 33% % reduction in the odds for POAF in cardiac surgery patients [22]. However, the limitations of this analysis were the significant heterogeneity found on OR calculations, reflecting the heterogeneity of different clinical settings included in the study and the presence of studies with small sample size. Recently, although Virani and colleagues [17] did not find any association between preoperative statin treatment and POAF in a large cohort of patients undergoing cardiac surgery, their multivariate analysis, even if not statistically significant, showed a trend toward an arrhythmic effect of statins use (OR, 1.13; 95% CI, 0.98 to 1.31; p = 0.08).

Use of ACE inhibitors before CABG, in our analysis, was interestingly an additional risk factor for POAF. Preoperative administration of ACE inhibitors in patients undergoing cardiac surgery may contribute to lowering of systemic vascular resistance and vasoplegia in the early postoperative phase, resulting in hypotension and requiring more fluids and inotropic or vasoconstrictor drugs [23, 24]. It is known that hypotension and volume overload are risk factors for new onset of POAF [4]. In addition, perioperative use of inotropic or vasoconstrictor drugs, by increasing sympathetic activation, may increase the risk of this arrhythmia after surgery [25, 26]. As a secondary end point, we found that the patients receiving statins had a 64% reduction in the risk of stroke events (8, 0.4%, versus 25, 1.2%; OR, 0.36; 95% CI, 0.14 to 0.71; p = 0.006) than those not receiving statins. Our results are similar to those of others who showed that statin therapy before surgery is significantly and independently associated with a lower risk of perioperative cerebrovascular events [27]. We believe that chronic statin treatment, through its antiatherogenic effects, could prevent the progression of atherosclerosis in the aorta as well as in cerebral arteries, a well-known source of stroke, reducing the risk of cerebrovascular accidents. However, the neuroprotective effect of statins needs to be more thoroughly investigated.

There are some limitations to our study. It is based on the retrospective analysis of our large institutional observational prospectively collected database. Propensity score analysis is simply a method for reducing bias in observational studies when randomization to treatment groups is not possible, and the matching was limited by available variables, which underlines the fact that selection bias could not be completely eliminated. Nevertheless, our study is based on a very large sample size compared with previously published data in this field and therefore does reflect the "real world" scenario. Another limitation is the lack of information about β-blockers, left atrial enlargement, timing and dose of preoperative statin treatment, unreported or undiagnosed episodes of POAF, chronic inflammatory disease, or postoperative variables such as volume overload or electrolyte imbalance (hypomagnesemia, hypokalemia).

In a large propensity-matched cohort of patients undergoing CABG surgery, preoperative statin treatment is associated with an increased risk of POAF. Although further work is necessary before any definitive recommendation, omitting statin drugs perioperatively and reinitiating them a few days after surgery might be a reasonable therapeutic option to reduce the risk of POAF while retaining their beneficial antiatherosclerotic effects for secondary prevention.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Villareal RP, Hariharan R, Liu BC, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery J Am Coll Cardiol 2004;43:742-748.[Abstract/Free Full Text]
  2. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society J Am Coll Cardiol 2006;48:e149-e246.[Free Full Text]
  3. Hogue CW, Creswell LL, Gutterman DD, Fleisher LA. Epidemiology, mechanisms, and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery Chest 2005;128:9-16.
  4. Echahidi N, Pibarot P, O'hara G, Mathieu P. Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery J Am Coll Cardiol 2008;51:793-801.[Abstract/Free Full Text]
  5. Engelmann MDM, Svedsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation Eur Heart J 2005;26:2083-2092.[Abstract/Free Full Text]
  6. Ishii Y, Schuessler RB, Gaynor SL, et al. Inflammation of atrium after cardiac surgery is associated with inhomogeneity of atrial conduction and atrial fibrillation Circulation 2005;111:2881-2888.[Abstract/Free Full Text]
  7. Abdelhadi RH, Gurm HS, Van Wagoner DR, Chung MK. Relation of an exaggerated rise in white blood cells after coronary bypass or cardiac valve surgery to development of atrial fibrillation post-operatively Am J Cardiol 2004;93:1176-1178.[Medline]
  8. Rosenson RS. Statins in atherosclerosis: lipid-lowering agents with antioxidant capabilities Atherosclerosis 2004;173:1-12.[Medline]
  9. Strandberg TE, Vanhanen H, Tikkanen MJ. Effect of statins on C-reactive protein in patients with coronary artery disease Lancet 1999;353:118-119.[Medline]
  10. Albert MA, Danielson E, Rifai N, et al. Effect of statin therapy on C-reactive protein levels: the pravastatin inflammation/CRP evaluation (PRINCE): a randomized trial and cohort study JAMA 2001;286:64-70.[Abstract/Free Full Text]
  11. Patti G, Chello M, Candura, et al. Randomized trial of atorvastatin for reduction of postoperative atrial fibrillation in patients undergoing cardiac surgery: results of the ARMYDA-3 (atorvastatin for reduction of myocardial dysrhythmia after cardiac surgery) study Circulation 2006;114:1455-1461.[Abstract/Free Full Text]
  12. Marìn F, Pascual DA, Ronldan V, et al. Statins and postoperative risk of atrial fibrillation following coronary artery bypass grafting Am J Cardiol 2006;97:55-60.[Medline]
  13. Mariscalco G, Lorusso R, Klersy C, et al. Observational study on the beneficial effect of preoperative statins in reducing atrial fibrillation after coronary surgery Ann Thorac Surg 2007;84:1158-1164.[Abstract/Free Full Text]
  14. Ozaydin M, Dogan A, Varol E, et al. Statin use before bypass surgery decrease the incidence and shortens the duration of postoperative atrial fibrillation Cardiology 2007;107:117-121.[Medline]
  15. Pan W, Pintar T, Anton J, Lee VV, Vaughn WK, Collard DC. Satins are associated with a reduced incidence of perioperative mortality after coronary artery bypass graft surgery Circulation 2004;110(Suppl 2)II-45-9.
  16. Powell BD, Bybee KA, Valeti U, et al. Influence of preoperative lipid-lowering therapy on postoperative outcome in patients undergoing coronary artery bypass grafting Am J Cardiol 2007;99:785-789.[Medline]
  17. Virani SS, Nambi V, Razavi M, et al. Preoperative statin therapy is not associated with a decrease in the incidence of postoperative atrial fibrillation in patients undergoing cardiac surgery Am Heart J 2008;155:541-546.[Medline]
  18. Blackstone EH. Comparing apples and oranges J Thorac Cardiovasc Surg 2002;123:8-15.[Free Full Text]
  19. Ascione R, Caputo M, Calori G, et al. Predictors of atrial fibrillation after conventional and beating heart coronary surgery: a prospective randomized study Circulation 2000;102:1530-1535.[Abstract/Free Full Text]
  20. Watters M, Ascione R, Ryder I, et al. Hemodynamic changes during beating heart coronary surgery with the "Bristol Technique" Eur J Cardiothorac Surg 2001;19:34-40.[Abstract/Free Full Text]
  21. Kourliouros A, De Souza A, Roberts N, et al. Dose-related effect of statins on atrial fibrillation after cardiac surgery Ann Thorac Surg 2008;85:1515-1520.[Abstract/Free Full Text]
  22. Liakopulos OJ, Choi YH, Haldenwang P, et al. Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30000 patients Eur Heart J 2008;29:1548-1559.[Abstract/Free Full Text]
  23. Tuman KJ, McCarthy RJ, O'Connor CJ, Holm WE, Ivankovich AD. Angiotensin-converting enzyme inhibitors increase vasoconstrictor requirements after cardiopulmonary bypass Anesth Analg 1995;80:473-479.[Abstract/Free Full Text]
  24. Carrel T, Englberger L, Mohacsi P, Neidhart P, Schmidli J. Low systemic vascular resistance after cardiopulmonary bypass: incidence, etiology, and clinical importance J Card Surg 2000;15:347-353.[Medline]
  25. Fleming GA, Murray KT, Chang Yu, et al. Milrinone use is associated with postoperative atrial fibrillation after cardiac surgery Circulation 2008;118:1619-1625.[Abstract/Free Full Text]
  26. Kalman JM, Munawar M, Howes LG, et al. Atrial fibrillation after coronary artery bypass grafting is associated with sympathetic activation Ann Thorac Surg 1995;60:1709-1715.[Abstract/Free Full Text]
  27. Aboyans V, Labrousse L, Lacroix P, et al. Predictive factors of stroke in patients undergoing coronary bypass grafting: statins are protective Eur J Cardiothorac Surg 2006;30:300-304.[Abstract/Free Full Text]

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