Elsevier

Heart Rhythm

Volume 9, Issue 2, February 2012, Pages 163-169
Heart Rhythm

Clinical
Atrial fibrillation
Statin Use And Postoperative Atrial Fibrillation After Major Noncardiac Surgery

https://doi.org/10.1016/j.hrthm.2011.09.003Get rights and content

Background

Although statin lipid-lowering medications likely reduce perioperative ischemic complications, few data exist to describe statins' effects on risk for and outcomes of atrial fibrillation following noncardiac surgery.

Objective

To examine the association between treatment with statin medications and clinically significant postoperative atrial fibrillation (POAF) following major noncardiac surgery.

Methods

A retrospective cohort study of patients aged 18 years or older who underwent major noncardiac surgery between January 1, 2008, and December 31, 2008. Cases of clinically significant POAF were selected by using a combination of International Classification of Diseases-9 codes and clinical variables. We defined statin users as those whose pharmacy data included a charge for a statin drug on the day of surgery, the day after surgery, or both.

Results

Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF; overall, 79,871 (21.6%) received a perioperative statin. Patients receiving statins were generally older (68.8 vs 61.1 years; P <.001) and more likely to be receiving a beta-blocker (50.3% vs 21.6%; P < .001). Statin use was associated with a lower unadjusted rate of POAF (2.6% vs 3.0%; P < .001). After adjustment for patient risk factors and surgery type, odds for POAF remained significantly lower among statin-treated patients (adjusted odds ratio = 0.79; 95% confidence interval = 0.71–0.87; P < .001). Statin use was not associated with differences in cost, length of stay, or mortality among patients who developed POAF.

Conclusion

Treatment with statin agents appears to be associated with a lower risk for clinically significant POAF following major noncardiac surgery.

Introduction

Atrial fibrillation affects approximately 2.5 million people in the United States and roughly 10% of people older than 80 years.1 The chronic form of this disease has been recognized as an epidemic and a major contributor to rising health-care costs. Recently, postoperative atrial fibrillation (POAF) after coronary artery bypass graft surgery has been associated with increased morbidity and health-care cost,2, 3 highlighting the need for strategies to minimize its occurrence.

Anti-inflammatory medications such as corticosteroids and ketorolac have been shown to decrease the incidence of POAF,4, 5 which is not unexpected, since the connection between surgery and atrial fibrillation is thought to be predominantly mediated by systemic inflammation.6, 7, 8 Unfortunately, these agents retard wound healing and increase bleeding complications. Statin medications have also been shown to decrease POAF (in the setting of cardiac surgery)9; the putative mechanism is thought to be related to the “pleiotropic” anti-inflammatory properties of statins, as well as their direct antiarrhythmic effect on pulmonary vein tissue.10

Statins are associated with reduced mortality following noncardiac surgery.11, 12 The specific mechanisms by which statins may lower mortality in this group of patients have not been fully elucidated. A decrease in the incidence of myocardial ischemia has been implicated, but a lower incidence of postoperative arrhythmia in those receiving perioperative statin therapy may be another mediator for this protective effect. Few studies, none large, have examined the relationship between statins and POAF following noncardiac surgery.13 For that reason, we carried out a study to examine the association between statin use and the incidence of POAF in a large cohort of patients undergoing major noncardiac surgery in a broad selection of hospitals in the United States.

Section snippets

Sites And Subjects

Data collected from patients hospitalized for noncardiac surgery at 375 US hospitals were utilized. These data were obtained from Perspective, a database developed for quality and utilization benchmarking by Premier Incorporated, Charlotte, NC. In addition to data elements available in the standard hospital discharge file, the Perspective database contains a date-stamped log at the individual patient level of all billed items, including medications as well as laboratory, diagnostic, and

Patient Characteristics

A total of 370,447 patients meeting eligibility criteria underwent major noncardiac surgery during the study period and were included in the analysis. Of these, 79,871 patients (21.6%) received a statin medication in the perioperative period (Table 1, Table 2). Patients treated with statin medications were older and were more often white. Statin-treated patients were more likely to have been admitted electively and to list Medicare/Medicaid as their primary form of insurance. Prevalence of

Discussion

In this large cohort of noncardiac surgical patients, the administration of statin medications in the perioperative time period was associated with markedly reduced odds of developing clinically significant POAF. Although the absolute observed effect size was small (a 0.4% reduction in POAF), the at-risk pool of patients undergoing major noncardiac surgery is very large. This modest risk reduction could drive relevant changes in health-care cost and outcomes when applied to millions of patients

Conclusion

Results from our large national observational study suggest that statin use is associated with significantly lower risk for atrial fibrillation following major noncardiac surgery and that this association is robust across a wide range of surgical procedures and patient groups. Statin use did not improve outcomes for patients in whom clinically significant POAF occurred, suggesting that statins' effect is in primary prevention of adverse events. While our data should not be used as support for

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    Dr Auerbach and Ms Maselli were supported by a midcareer development grant from NHLBI (grant number K24HL098372) during this research. Dr Goldman was supported by an AHRQ K08 Mentored Clinical Scientist Development Award (grant number 1 K08 HS018090-01) and NIH/NCRR UCSF-CTSI grant (grant number UL1 RR024131).

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