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Division of Cardiac Surgery, University of Maryland Medical Center N4W94, 22 S Green St, Baltimore, MD 21201
(Email: jgammie{at}smail.umaryland.edu).
Miceli and colleagues [1] examined the association between preoperative statin use and the incidence of postoperative atrial fibrillation (AF) in a large retrospective observational study and found, in contrast to most previous reports, that statin use was associated with a reduction in the incidence of postoperative AF. They used propensity-matching techniques to identify a subset of statin-treated patients who were comparable with untreated patients.
Although the finding that the incidence of postoperative AF decreased from 19.5% to 15.8% was statistically significant, the overall clinical significance of a 3.7% absolute reduction in postoperative AF is less certain. The authors report a dramatic and highly significant threefold reduction in the risk of stroke among patients taking statins, and that may be the most important message of this work.
Retrospective observational studies of large populations have tremendous value, but it is instructive to consider how one might construct a prospective randomized study to test a clinically important question: in this case, should statins be initiated (or stopped) before a patient undergoes coronary artery bypass grafting? Key variables that would be held constant in such a study would include the type of drug administered, the dose and duration of administration before operation, the duration of postoperative AF surveillance, and the definition of AF. Defined end points would include the presence of postoperative AF and the AF burden and its effect on hospital stay, complications, and death.
Problematic in the present study, and in any retrospective study of drug effects in patients undergoing cardiac operations is that data are unavailable for many of these variables. Although logistic regression and propensity-matching techniques can account for measured covariates, the presence of a large number of unmeasured covariates makes it difficult to draw firm conclusions when assessing the effect of a pharmaceutical on outcomes after cardiac operations.
Miceli and colleagues [1] are to be congratulated on a provocative finding: this work is hypothesis generating and will hopefully stimulate the performance of appropriately powered randomized trials. Upstream preoperative pharmaceutical therapy to optimize outcomes in cardiac surgery is a tantalizing and important goal.
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