Perioperative Statin Therapy: Are Formal Guidelines and Physician Education Needed?

Abstract

Charles D. Collard, MD In this issue of Anesthesia & Analgesia, Le Manach et al. add to the growing evidence that perioperative statin therapy reduces surgical morbidity and mortality (1–6). Moreover, data from these same authors and others suggest that postoperative discontinuation of statin therapy is associated with worsened cardiac outcomes after major cardiovascular surgery (1,2). Thus, administration of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or “statins,” may be one of the most important perioperative therapeutic regimens to reduce the risk of postoperative cardiovascular complications in high-risk surgical patients since the introduction of -blockers into the operative setting (6). However, unlike the situation with perioperative -blocker therapy, the American College of Cardiology/American Heart Association Task Force on Practice Guidelines have yet to publish a consensus statement regarding perioperative statin therapy. Current National Cholesterol Education Program Adult Treatment Panel guidelines recommend decreasing LDL levels to 100 mg/dL in patients with known coronary disease, and more aggressive statin therapy to decrease LDL levels to 70 mg/dL in patients with coronary disease and high risk factors such as diabetes, hypertension, obesity, smoking, the metabolic syndrome, and acute coronary syndromes (ACS) (7). Thus, on the basis of these guidelines, most patients undergoing major cardiovascular surgery would qualify for statin therapy. Yet, despite these guidelines, it is estimated that up to two-thirds of eligible candidates may not be receiving statin therapy at hospital discharge (8). Explanations for not starting or reinitiating statin therapy after cardiovascular surgery may include patients’ decreased tolerance of oral medications secondary to nausea and vomiting, transient renal dysfunction, concerns pertaining to hepatic toxicity or myositis, or failure of the responsible physician to reimplement preoperative medications. The most serious potential statin side effect is rhabdomyolysis. Cerivastatin, which is no longer on the market, carried the greatest risk of this complication (3.16 per million prescriptions). In contrast, the risk of statin-induced rhabdomyolysis ranges only from 0 to 0.19 per million prescriptions for the other commonly used statins (9). Furthermore, the risk for rhabdomyolysis is associated with factors that increase serum statin concentrations, such as small body size, advanced age, renal or hepatic dysfunction, diabetes, hypothyroidism, and drugs that interfere with statin metabolism, such as cyclosporin, antifungal drugs, calciumchannel blockers, and amiodarone (9). When this small risk is compared with the incidence and socioeconomic cost of cardiac perioperative morbidity and mortality after major cardiovascular surgery, the benefits of statin therapy seem to largely outweigh any potential risks in the vast majority of patients. Moreover, in a recent study by Schouten et al., perioperative statin use in a large group of patients was not associated with an increased risk of perioperative myopathy or increased creatine phosphokinase levels after major vascular surgery (10). Indeed, after correcting for cardiac risk factors and clinical risk factors for myopathy, length of surgery remained the only independent predictor for myopathy From the Division of Cardiovascular Anesthesiology, Baylor College of Medicine, Texas Heart Institute, St. Luke’s Episcopal Hospital, Houston, Texas. Accepted for publication March 6, 2007. Address correspondence to Charles D. Collard, MD, Baylor College of Medicine, Texas Heart Institute, St. Luke’s Episcopal Hospital, 6720 Bertner Ave., Houston, TX 77030. Address e-mail to ccollard@heart.thi. tmc.edu. Copyright © 2007 International Anesthesia Research Society