Perioperative statins: More than lipid-lowering?
ABSTRACTPreliminary evidence indicates that statin drugs may be beneficial when given in the perioperative period. Although more studies are needed to draw firm conclusions, the acute nonlipid pleiotropic effects of statins may improve patient outcomes, especially for patients at the highest risk.
KEY POINTS
- Experiments in animals suggest that statins, given shortly before or after a cardiovascular event, confer benefit before any changes in lipids are measurable.
- Retrospective and prospective studies indicate that patients with either acute myocardial infarction or acute coronary syndrome who are already receiving statins should not have them stopped, and those who had not been receiving statins should receive them immediately.
- Most patients undergoing coronary artery bypass grafting or noncardiac vascular surgery should already be receiving a statin. These drugs can also be considered in patients undergoing intermediate-risk nonvascular surgery. Patients who have been receiving statins prior to surgery should not have them stopped for surgery.
OUR RECOMMENDATIONS
Before CABG or vascular surgery
Given the NCEP recommendations, existing primary and secondary prevention studies, observational studies of CABG and noncardiac vascular surgery patients, and the one randomized trial of vascular surgery patients, data support the use of statins in nearly all patients undergoing cardiac or vascular surgery. We advocate starting statins in the perioperative period to take advantage of their rapid-acting pleiotropic effects, and continuing them long-term to take advantage of their lipid-lowering effects. This recommendation is in line with the recently released American College of Cardiology/American Heart Association (ACC/AHA) 2007 perioperative guidelines that state “for patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable.”42
Although the ideal time to start statins is not certain, the study by Durazzo et al23 suggests that they should be started at least 2 weeks before surgery if possible. Moreover, patients already taking statins should definitely not have their statins discontinued if at all possible.
Before major nonvascular surgery
For patients undergoing major nonvascular (intermediate-risk) surgery, physicians should first ascertain if the patient has an indication for statin therapy based on current nonsurgical lipid level recommendations. However, even if there is no clear indication for statin therapy based on NCEP guidelines, we endorse the recently released ACC/AHA perioperative guidelines that state that statin therapy can be considered in patients with a risk factor who are undergoing intermediate-risk procedures. Moreover, we wholeheartedly support the ACC/AHA’s strongest recommendation that patients who are already receiving statins and are undergoing noncardiac surgery should not have their statins discontinued.
When to discontinue statins?
The risk of harm overall appears to be minimal and certainly less than the likelihood of benefit. It is reasonable to observe patients postoperatively for adverse clinical events that may increase the risk of perioperative statin treatment, such as acute renal failure, hepatic failure, or sepsis, but whether statins should be stopped in patients with these complications remains unknown; we advocate individualizing the decision.
More studies needed
We need more data on whether moderate-risk patients undergoing moderate-risk surgery benefit from perioperative statin therapy, when therapy should be started, whether therapy should be started on the day of surgery if it was not started earlier, which statin and what doses are optimal, how long therapy should be continued, and what degree of risk is associated with perioperative statin therapy.
Fortunately, important data should be forthcoming in the next few years: the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-IV) study43 is a 4-year two-by-two factorial placebo-controlled study evaluating the use of fluvastatin (Lescol) and bisoprolol (Zebeta, a beta-blocker) separately and together in patients who are older than 40 years, are undergoing elective noncardiac surgery, have an estimated risk of cardiovascular death of more than 1%, have not used statins previously, and do not have elevated cholesterol.
