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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Effect of perioperative statins on death, myocardial infarction, atrial fibrillation, and length of stay: a systematic review and meta-analysis

V Chopra, DH Wesorick, JB Sussman, T Greene, M Rogers, JB Froehlich, KA Eagle, and S Saint.

Review published: 2012.

Link to full article: [Journal publisher]

CRD summary

This review concluded that perioperative statin treatment decreased atrial fibrillation, myocardial infarction and duration of hospital stay in statin-naive patients who underwent cardiac or non-cardiac surgery. The authors' conclusions reflect the evidence presented. A degree of caution might be required in interpreting the conclusions given the uncertain quality of some of the included studies.

Authors' objectives

To evaluate the influence of perioperative statin treatment on the risk of death, myocardial infarction, atrial fibrillation and hospital length of stay in statin-naive patients undergoing cardiac or non-cardiac surgery.

Searching

PubMed, EMBASE, BIOSIS Previews and Cochrane Central Register of Controlled Trials (CENTRAL). Search terms were reported. ClinicalTrials.gov, web portals of International Federation of Pharmaceutical Manufacturers and Pharmaceutical Research and Manufacturers of America were searched for unpublished and ongoing clinical trials. The Conference Proceedings Index provided by Cambridge Scientific Abstracts was searched. Reference lists of relevant publications were screened. Study authors and experts in the field were contacted for any additional studies.

Study selection

Randomised controlled trials (RCTs) that included a contemporaneous control group in statin-naive patients (18 years or older) who underwent cardiac or non-cardiac surgery were eligible for inclusion. Eligible studies had to recruit patients not maintained on long-term statin treatment (statin-naive). Eligible studies were also required to report at least one of the outcomes: death, myocardial infarction, atrial fibrillation and length of intensive care unit (ICU) and hospital stays. Studies that evaluated percutaneous coronary interventions or cardioversion were excluded.

The included studies evaluated various types of statin that included fluvastatin, rosuvastatin, atorvastatin, simvastatin and pravastatin. Statin doses and regimens varied between studies. It appeared that placebo was the comparator in most studies. Total duration of statin treatment varied from three to 67 days. Preoperative treatment duration ranged from two to 37 days. Postoperative treatment duration ranged from seven to 30 days. Most studies involved cardiac surgery; some involved non-cardiac or vascular surgery. Where reported, most patients were male.

Two reviewers independently assessed studies for inclusion. Any disagreements were resolved by consensus or by a third reviewer.

Assessment of study quality

Study quality was assessed using the tool described by the Cochrane Statistical Methods Group. Each study was classified as low-risk, unclear or high-risk for bias. Studies that reporting all the quality domains using appropriate methods were judged to be of low risk of bias.

The authors did not state how many reviewers performed quality assessment.

Data extraction

For dichotomous outcomes, data were extracted on event rates to enable calculation of relative risks (RRs) with 95% CIs. For continuous outcomes, data were extracted on means and standard deviations to enable calculation of mean differences with 95% CIs. Study authors were contacted for missing data where necessary.

Two reviewers independently performed data extraction.

Methods of synthesis

The studies were combined in a meta-analysis. Pooled relative risks and standardised mean differences (SMDs), with 95% CIs, were calculated using the DerSimonian and Laird random-effects model. Statistical heterogeneity was assessed using the Cochran Q and Ι² statistics. Numbers needed to treat (NNT) were calculated. Publication bias was assessed using the Harbord test and Eggers test.

Subgroup analyses were conducted to determine the impact of type of surgery or potency or duration of statin treatment on outcomes. Sensitivity analyses were conducted by fitting fixed-effect models and excluding non-placebo comparator arm studies, cardiac surgery studies or studies of low and unclear quality.

Results of the review

Fifteen RCTs were included in the review (2,292 participants). Seven RCTs were at low risk of bias, three were at high risk of bias and five had unclear risk of bias.

Perioperative statin treatment in patients who underwent cardiac surgery was associated with a significant reduction in the risk of atrial fibrillation compared with controls (RR 0.56, 95% CI 0.45 to 0.69; NNT=6; nine RCTs).

Perioperative statin treatment in patients who underwent cardiac and noncardiac surgery was associated with a significant reduction in the risk of myocardial infarction compared with controls (RR 0.53, 95% CI 0.38 to 0.74; NNT=23; 10 RCTs) but not in the risk of death (RR 0.62, 95% CI 0.34 to 1.14; five RCTs).

Perioperative statin treatment was associated with a significant reduction in length of hospital stay compared with controls (SMD -0.32 days, 95% CI -0.53 to -0.11; 12 RCTs). There was no significant difference in length of intensive care unit stay between the two groups.

Significant heterogeneity was only observed on the outcome of length of hospital stay (Ι²=78.7%). There was no evidence of publication bias for most outcomes. Sensitivity and subgroup analyses did not materially alter most outcomes.

Authors' conclusions

Perioperative statin treatment decreased atrial fibrillation, myocardial infarction and duration of hospital stay in statin-naive patients who underwent cardiac or non-cardiac surgery.

CRD commentary

This review's inclusion criteria were clear. Relevant databases were searched. Efforts were made to find both published and unpublished studies, which reduced potential for publication bias. Publication bias was assessed and little evidence of it was found. Sufficient attempts were made to minimise biases and errors during study selection and data extraction; it was unclear whether quality assessment was also performed in duplicate. Appropriate criteria were used to assess study quality. Statistical heterogeneity was assessed and appropriate methods were used to pool the results.

The authors' conclusions reflect the evidence presented. A degree of caution might be required in interpreting the conclusions given the uncertain quality of some of the included studies.

Implications of the review for practice and research

Practice: The authors stated that perioperative practice and guidelines should be modified to incorporate wider use of statins in patients undergoing surgery.

Research: The authors did not state any implications for research.

Funding

One author was funded by the Clinical and Translational Science Award, Michigan Institute for Clinical and Health Research, USA.

Bibliographic details

Chopra V, Wesorick DH, Sussman JB, Greene T, Rogers M, Froehlich JB, Eagle KA, Saint S. Effect of perioperative statins on death, myocardial infarction, atrial fibrillation, and length of stay: a systematic review and meta-analysis. Archives of Surgery 2012; 147(2): 181-189. [PubMed: 22351917]

Indexing Status

Subject indexing assigned by NLM

MeSH

Atrial Fibrillation /epidemiology /prevention & control; Cardiac Surgical Procedures /adverse effects; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors /therapeutic use; Length of Stay; Myocardial Infarction /epidemiology /prevention & control; Perioperative Care; Postoperative Complications /prevention & control; Randomized Controlled Trials as Topic

AccessionNumber

12012013223

Database entry date

06/10/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 22351917

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