Peri‐operative statin therapy

Abstract

Both Yates et al and Biccard discuss the indications for peri-operative statin therapy and the current lack of evidence for starting statins in patients at risk of peri-operative coronary events [1, 2]. Whilst there is little evidence that statin therapy reduces peri-operative risk, we feel that it would be appropriate to initiate statin therapy in patients in whom it is medically indicated. Unfortunately many patients continue to present for major surgery without medically indicated statin therapy. Furthermore, in many of the major studies looking at peri-operative β-blocker therapy, statin therapy appears to be under-utilised. National guidelines recommend that patients with established cardiovascular disease or those over the age of 40 years with a high risk of having a first cardiovascular event should be considered for statin therapy [3]. In the recently published POISE study [4], it is likely that the majority of patients would have fulfilled these criteria but only 32% were receiving statin therapy. Juul et al [5] investigated β-blockade in patients with diabetes undergoing major non-cardiac surgery. Patients over the age of 40 years with diabetes should be considered for statin therapy [3] and therefore virtually all patients enrolled should have been on a statin. Less than 11% received statin therapy. In the POBBLE study [6] all subjects underwent infrarenal vascular surgery and statin therapy would have been indicated in more than the reported 31% who were actually receiving it. Statins may be under prescribed in the primary care setting. A recent survey suggested that only 45% of general practitioners would prescribe statins for peripheral vascular disease [7]. Under-prescribing also occurs in secondary care as up to two-thirds of patients eligible for statin therapy may not be receiving them at the time of hospital discharge [8]. As statins appear to be safe in the peri-operative period [9, 10], it would seem prudent to ensure that all patients with medical indications should be on statin therapy before they undergo surgery, and anaesthetists can play an important role in optimising such therapy.