Statin降低心臟手術後發生心律不整的風險


  March 14, 2006(亞特蘭大訊)-一項收納接受選擇性心臟手術的安慰劑控制試驗結果顯示,每天使用40毫克atrovastatin,於手術後開始服用且持續1個月,可顯著地降低術後發生心房顫動(AF)風險。
  
  術後發生AF是很常見的,舉例來說,冠狀動脈繞道手術(CABG)發生心律不整的發生率超過40%,在心臟瓣膜置換手術,AF發生率超過50%。
  
  在Atorvastatin for Reduction of MYocardial Dysrrhythmia After cardiac surgery(ARMYDA-3)試驗中,義大利羅馬大學生物醫學校區心臟科學部門Germano Di Sciascio醫師隨機分派200位過去未使用過statin類藥物的病患接受atorvastatin或是安慰劑;過去有AF病史病患被排除在試驗之外。
  
  該試驗的主要終點為持續5分鐘以上的AF,次級試驗終點為術後30天發生重大不良心血管與腦血管事件(MACCE)機率;試驗前與手術後每24小時測量一次C反應蛋白,直到出院前。
  
  Di Sciascio醫師表示,使用atorvastatin病患發生AF的盛行率為35%,相較於安慰劑組的57%;使用atorvastatin病患住院時間也比使用安慰劑病患短(6.3天相較於6.9天);Di Sciascio醫師表示,雖然差異不大,但是統計上是有顯著意義的。
  
  術後兩組之間的C反應蛋白差異不大,沒有AF病患的濃度大約為120至150 mg/L,不論是哪一組病患,有AF的病患大約為180 mg/L;死亡率、心肌梗塞率與再次接受血管手術率都沒有差異,每組病患中皆有2位死亡、3位發生心肌梗塞,但沒有人再次接受血管手術;一位接受安慰劑病患發生中風,但是服用atorvastatin病患沒有人發生中風。
  
  Di Sciascio醫師表示,使用atorvastatin病患未發生事件存活率為60%、使用安慰劑病患為40%,換算為使用atorvastatin可以降低60%整體風險;藥物不良反應率非常的低。
  
  Di Sciascio醫師指出,這是第一項顯示statin類藥物可以降低術後風險的試驗;他表示,atorvastatin透過抑制發炎而造成這些作用。
  
  麥迪遜威斯康辛大學心臟血管醫學副教授,同時也是今年ACC科學座談副主席James H. Stein醫師向Medscape表示,我很高興你們報導這項試驗,這是項很小但是很重要的研究,比其他於今年同時發表的研究相比,該試驗較容易應用於執業上。
  
  Stein醫師表示,目前對於術後發生AF的標準療法為使用抗心律不整藥物,這些藥物是具有毒性的藥物。
  
  沒有人知道為什麼心臟手術會造成心律不整,手術可能刺激心房,而引起發炎;Stein醫師表示,這可以解釋為什麼statin類藥物會有效。
  
  Stein醫師附帶表示,我不認為atorvastatin只限於抗心律不整作用,但是這是第一個前瞻性試驗。

Statin Reduces Risk of Arrhyth

By Martha Kerr
Medscape Medical News

March 14, 2006 (Atlanta) — A placebo-controlled trial of patients scheduled for elective heart surgery shows that atorvastatin, 40 mg daily, for 1 week prior to surgery and continued for 1 month afterward significantly reduces the risk of postoperative atrial fibrillation (AF).

The incidence of postoperative AF is a common complication after heart surgery. For example, the incidence of AF after coronary artery bypass graft (CABG) surgery is associated with a more than 40% incidence of arrhythmias, and after valve surgery, the incidence of AF is more than 50%.

In the Atorvastatin for Reduction of MYocardial Dysrrhythmia After cardiac surgery (ARMYDA-3) trial, chairman Germano Di Sciascio, MD, from the Department of Cardiovascular Sciences at the Campus Bio-Medico University of Rome, Italy, and colleagues randomized 200 statin-naive patients to atorvastatin therapy or placebo. All patients were scheduled for elective CABG surgery or valve replacement/repair. Patients with a history of AF were excluded from the study.

The study's primary end point was AF lasting longer than 5 minutes; the secondary end point was 30-day incidence of major adverse cardiovascular and cerebral events (MACCE). C-reactive protein levels were measured at baseline and every 24 hours postoperatively until discharge.

Dr. Di Sciascio announced that there was a 35% incidence of AF with atorvastatin compared with 57% in the placebo group. Use of atorvastatin was also associated with a shorter duration of hospital stay compared with the placebo group (6.3 days vs 6.9 days, respectively). "This may not seem like much of a difference, but it was statistically significant," Dr. Di Sciascio commented.

C-reactive protein levels after surgery were similar between the 2 groups, at approximately 120 to 150 mg/L in patients without AF, regardless of study group, and approximately 180 mg/L in patients with AF. Incidence of death, myocardial infarction, and revascularization were the same with statin and placebo, occurring in 2, 3 and none of the patients in each group, respectively. One patient receiving placebo had a stroke, while there were none in the atorvastatin group.

The rates of event-free survival were 60% in the atorvastatin group vs 40% of patients in the placebo group, accounting for an overall 60% risk reduction in events in patients receiving atorvastatin. The incidence of adverse drug effects was very low, Dr. Di Sciascio reported.

"This is the first study to show that a specific statin will decrease risk of events after surgery," Dr. Di Sciascio pointed out. He speculated that atorvastatin exerts its beneficial effects through its anti-inflammatory activity.

"I'm glad you're covering this study," James H. Stein, MD, associate professor of cardiovascular medicine at the University of Wisconsin in Madison, and cochair of this year's ACC Scientific Session, told Medscape. "It is a small but very important trial that is going to bear more quickly on the practice of medicine than a lot of other studies presented this year."

Dr. Stein noted that the current standard of care for postoperative AF is anti-arrhythmic drug therapy, "which are very toxic agents. Statins are nearly benign.

"No one knows for sure why heart surgery causes arrhythmias. It may have something to do with irritation of the atria, which causes inflammation," Dr. Stein suggested. This would explain the positive effect that statins have in this setting, he said.

"I don't think the [anti-arrhythmic] effects would be limited to atorvastatin, but this is the first prospective trial," Dr. Stein added.

ACC 55th Scientific Session: Abstract 405-6. Presented March 12, 2006.

Reviewed by Ariana Del Negro

    
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