Author's Reply

To the Editor,

We thank the authors for their comments on our article entitled “Efficiency of postoperative statin treatment for preventing new onset postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting: a prospective randomized study” published in the June 2014 issue of Anatol J Cardiol (1). Our prospective randomized study with statin therapy regimen in the early postoperative period showed a statistically significant decrease in postoperative new-onset AF and a significant decrease in CRP levels in patients undergoing isolated CABG (1).

Preoperative statin therapy is also shown to reduce the incidence of postoperative AF (2, 3). Recently, CABG is frequently performed on the day after coronary angiography; therefore, preoperative statin therapy cannot be administered in most of the patients. Sakamoto et al. (2) detected a delay of approximately 2 days in the occurrence of AF in patients with preoperative statin therapy versus without statin therapy. The patients did not undergo preoperative statin therapy in our study, and we did not detect any difference in the occurrence day of the first postoperative AF. Therefore, we suggest that statin therapy should be started preoperatively, if possible (1). ARMYDA-3 was the first randomized controlled trial to evaluate the impact of preoperative statin therapy on postoperative AF. This was the largest randomized study. Atorvastatin was administered 7 days before heart surgery. As a result, preoperative atorvastatin reduced the risk of postoperative AF (3).

Recent studies have shown that statins reduce the CRP level in 2 weeks (4-6). Sakamoto et al. (2) started the statin therapy in the preoperative period and have shown that statins reduce the CRP level on the seventh postoperative day. Moreover, other mechanisms may contribute to the clinical benefit of statins, antioxidant effects, direct antiarrhythmic effects by cell membrane ion channel stabilization, improvement of coronary flow velocity reserve by vasodilation of coronary micro vessels, rapid (<12 h after a single dose of atorvastatin) improvement of endothelial function, or direct protection of the myocardium also plays a role in extracellular matrix modulation (3, 6). These effects may contribute to the prevention of AF of statins. Therefore, we suggest that routine administration of statins is useful in patients undergoing elective CABG for prevention of postoperative AF. In our study, CRP levels were significantly lower in patients without AF versus those with AF. CRP levels on the 14^th postoperative day were significantly lower in the statin group compared with those in the non-statin group.

Atorvastatin undergoes rapid absorption when taken orally, with an approximate time to reach maximum plasma concentration (Tmax) of 1-2 h. The absolute bioavailability of the drug is approximately 14%; however, the systemic availability for HMG-CoA reductase activity is approximately 30% (7). Thus, based on pharmacokinetics, the drug should be active and effective during the first postoperative day. Each extubated patient was given 40 mg of atorvastatin per day, which was started on an average of 6 h after the operation. All patients are able to take oral statin. Therefore, we suggest that if preoperative statin therapy is not administered to patients, statin therapy should be started in a short time postoperatively to obtain the beneficial effects of statins.