Usefulness of statins in preventing atrial fibrillation in patients with permanent pacemaker: a systematic review

Patients with permanent pacemakers (PM) are at high risk of developing atrial fibrillation (AF). Minimal ventricular pacing modalities have been demonstrated to reduce AF in such patients, although they are not suitable for patients with advanced atrioventricular conduction disease. Recent evidences suggest that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (i.e. statins) may represent a new strategy to prevent AF in patients at risk. In this article, we sought to review data regarding the effectiveness of statin therapy in preventing AF patients with a PM. We reviewed all available studies that assessed the effect of statin therapy on the occurrence of AF in patients with PM, implanted due to sinus node dysfunction or atrioventricular conduction disease. Moreover, a random effect inverse variance-weighted meta-analysis was performed, by entering directly the logarithm of the hazard ratio (HR) of AF provided in the multiple Cox regression analyses from each study. Three studies were identified, including 552 patients, of whom 159 received statins. Follow-up ranged from 1 to 2.77 years. Two studies (one observational and one prospective randomized) included predominantly patients with sinus node dysfunction (70% and 91% of patient population, respectively) and, consistently, showed a beneficial effect of statins on the occurrence of AF. On the other hand, the study including predominantly patients with atrioventricular block (60% of patient population) failed to show a beneficial effect of statins on AF occurrence. The HR for AF occurrence for the cumulative data was found to be 0.43 (95% confidence interval: 0.28-0.67, P < 0.001). Statistical heterogeneity between included studies was not detected (chi(2) = 1.68, P = 0.43, I(2) = 0%), although significant clinical differences were found in terms of study design, patient populations, statins use and dosage and AF-monitoring capabilities. Statins may represent a novel treatment strategy to prevent the occurrence of AF in patients with PM, especially for those who had a PM implanted due to sinus node dysfunction. Basing on our findings, a randomized clinical trial with a proper design to evaluate the utility of statins in preventing AF in these patients is warranted.