Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry

Danilo Menichelli; Emilia Antonucci; Pasquale Pignatelli; Francesco Violi; Gualtiero Palareti; Daniele Pastori; START2 Register Investigators

doi:10.1016/j.numecd.2023.07.016

Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry

Nutr Metab Cardiovasc Dis. 2023 Nov;33(11):2261-2268. doi: 10.1016/j.numecd.2023.07.016. Epub 2023 Jul 28.

Authors

Danilo Menichelli¹, Emilia Antonucci², Pasquale Pignatelli³, Francesco Violi³, Gualtiero Palareti², Daniele Pastori⁴; START2 Register Investigators

Collaborators

START2 Register Investigators:
Sophie Testa⁵, Benilde Cosmi⁶, Giuliana Guazzaloca⁶, Ludovica Migliaccio⁶, Daniela Poli⁷, Rossella Marcucci⁷, Niccolò Maggini⁷, Vittorio Pengo⁸, Anna Falanga⁹, Teresa Lerede⁹, Lucia Ruocco¹⁰, Giuliana Martini¹¹, Simona Pedrini¹², Federica Bertola¹², Lucilla Masciocco¹³, Pasquale Saracino¹³, Angelo Benvenuto¹³, Claudio Vasselli¹⁴, Francesco Violi¹⁵, Pasquale Pignatelli¹⁵, Daniele Pastori¹⁵, Elvira Grandone¹⁶, Donatella Colaizzo¹⁶, Marco Marzolo¹⁷, Mauro Pinelli¹⁸, Daniela Mastroiacovo¹⁸, Walter Ageno¹⁹, Giovanna Colombo¹⁹, Eugenio Bucherini²⁰, Domizio Serra²¹, Andrea Toma²², Pietro Barbera²², Carmelo Paparo²³, Antonio Insana²⁴, Serena Rupoli²⁵, Giuseppe Malcangi²⁶, Maddalena Loredana Zighetti²⁷, Catello Mangione²⁸, Domenico Lione²⁹, Paola Casasco³⁰, Giovanni Nante³¹, Alberto Tosetto³², Vincenzo Oriana³³, Nicola Lucio Liberato³⁴

Affiliations

¹ Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy.
² Fondazione Arianna Anticoagulazione, Bologna, Italy.
³ Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
⁴ Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy. Electronic address: daniele.pastori@uniroma1.it.
⁵ Oriana Paoletti, UO Laboratorio Analisi, Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy.
⁶ UO di Angiologia e Malattie Coagulazione, AOU S. Orsola-Malpighi, Bologna, Bologna, Italy.
⁷ SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy.
⁸ Dipartimento di Scienze Cardio-Toraco-Vascolari, Centro Trombosi, AOU Padova, Padova, Italy.
⁹ USC SIMT, Centro Emostasi e Trombosi, Ospedale Papa Giovanni XXIII, Bergamo, Italy.
¹⁰ U.O. Analisi Chimico-Cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.
¹¹ Centro Emostasi, Spedali Civili Di Brescia, Brescia, Italy.
¹² Servizio di Laboratorio, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
¹³ UOC Medicina Interna, Centro Controllo Coagulazione, Presidio Ospedaliero Lastaria, Lucera, Foggia, Italy.
¹⁴ Laboratorio Patologia Clinica, Policlinico Casilino, Roma, Italy.
¹⁵ Centro Trombosi, Clinica Medica Policlinico Umberto I, Università la Sapienza Roma, Italy.
¹⁶ Centro Trombosi Casa del Sollievo e della Sofferenza, S.Giovanni Rotondo, Foggia, Italy.
¹⁷ UOC Medicina Interna, Ospedale di Rovigo, Italy.
¹⁸ UOSD Angiologia e Diagnostica Vascolare, Ospedale SS Filippo e Nicola, Avezzano, L'Aquila, Italy.
¹⁹ UO. Medicina I, Ospedale di Circolo, Varese, Italy.
²⁰ SS Medicina Vascolare-Angiologia, Ambulatorio Anticoagulanti, Ospedale Civile di Faenza, Faenza, Ravenna, Italy.
²¹ Centro Trombosi, Ospedale Evangelico Internazionale, Genova, Italy.
²² UOC di Patologia Clinica, Ambulatorio Terapia Anticoagulante Orale, O.C. "L.Cazzavillan", Arzignano, Vicenza, Italy.
²³ Patologia Clinica, Ospedale Maggiore Chieri, Torino, Italy.
²⁴ SC Patologia Clinica, Ospedale Santa Croce Moncalieri, Moncalieri, Torino, Italy.
²⁵ Clinica Ematologica, AOU-Ospedali Riuniti Ancona, Ancona, Italy.
²⁶ Centro Emofilia e Trombosi, Policlinico di Bari, Bari, Italy.
²⁷ SIMT-AO San Paolo, Milano, Italy.
²⁸ Sezione Trasfusionale Ospedale di Galatina, Galatina, Lecce, Italy.
²⁹ UOC Patologia Clinica, Ospedale Perrino, Brindisi, Italy.
³⁰ Servizio Medicina Trasfusionale, Tortona, Alessandria, Italy.
³¹ UOS Geriatria ULSS 16 Padova, Padova, Italy.
³² Divisione di Ematologia, Ospedale San Bortolo, Vicenza, Italy.
³³ Centro Emofilia, Presidio Ospedaliero Morelli, Reggio Calabria, Italy.
³⁴ UO Medicina Interna Ospedale di Casorate Primo, Pavia, Italy.

PMID: 37580234
DOI: 10.1016/j.numecd.2023.07.016

Abstract

Background and aims: Statins are mainstream drugs for cardiovascular (CV) prevention, but under-prescription is an important clinical challenge. Data on the use of single statins and on the rate of under-prescription in atrial fibrillation (AF) are lacking. We evaluated the association of statin underuse with mortality risk in a large AF cohort.

Methods and results: As many as 5477 patients from the Italian nationwide START registry were included. The prevalence of different statins was reported and the association of under prescription with all-cause and CV mortality investigated. Mean age was 80.2 years, and 46.4% were women. Among 2899 patients with a clinical indication to statin, only 1578 (54.4%) were on treatment. In a mean follow-up of 22.5 ± 17.1 months, 491 (4.7%/year) deaths occurred (106 CV deaths, 1.0%/year). Atorvastatin and Simvastatin were inversely associated with all-cause (HR 0.692, 95% CI 0.519-0.923, p = 0.012 and HR 0.598, 95% CI 0.428-0.836, p = 0.003, respectively) and CV death (HR 0.372, 95% CI 0.178-0.776, p = 0.008 and HR 0.306, 95% CI 0.123-0.758, p = 0.010, respectively). The 1321 untreated patients were older, more frequently women and with a higher prevalence of diabetes, previous cerebrovascular disease, peripheral artery disease compared to those on treatment. Statin undertreatment was associated with higher risk of all-cause (HR 1.400, 95% CI 1.078-1.819, p = 0.012) and CV death (HR 2.057, 95% CI 1.188-3.561, p = 0.010).

Conclusions: AF patients with an indication to statins but left untreated show a high risk of all-cause and CV mortality. Implementation of statin prescription in the AF population can help reducing the residual mortality risk.

Keywords: All-cause mortality; Atrial fibrillation; Cardiovascular death; Dyslipidaemia; Under prescription; statins.

Copyright © 2023 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.