Abstract
In this review, we discuss clinical evidence-based data regarding the potential benefit of statin therapy in the perioperative period of non-cardiac surgery. Results from meta-analyses of prospective observational studies have provided conflicting evidence. Moreover, comparison among studies is complicated by varying data sources, outcome definitions, types of surgery, and preoperative versus perioperative statin therapy. However, results of two recent large prospective cohort studies showed that statin use on the day of or the day after non-cardiac surgery (or both) is associated with lower 30-day all-cause mortality and reduction in a variety of postoperative complications, predominantly cardiac, compared with non-use during this period. There is a paucity of data from randomized controlled trials assessing the benefit of statin therapy in non-cardiac surgery. No randomized controlled trials have shown that initiating a statin in statin-naïve patients may reduce the risk of cardiovascular complications in non-cardiac surgeries. One randomized clinical trial demonstrated that the use of a preoperative statin in patients with stable coronary heart disease treated with long-term statin therapy had a significant reduction in the incidence of myocardial necrosis and major adverse cardiovascular events after non-cardiac surgery. In conclusion, it is important that all health-care professionals involved in the care of the surgical patient emphasize the need to resume statin therapy, particularly in patients with established atherosclerotic cardiovascular disease. However, initiating a statin in statin-naïve patients undergoing non-cardiac surgery needs more evidence-based data.
Highlights
Many patients undergoing surgery take medicines used to prevent atherothrombotic cardiovascular events
In the Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial[15], reported by Berwanger et al, 648 statin-naïve patients who were at risk for a major vascular complication and scheduled for non-cardiac surgery were randomly assigned to a loading dose of atorvastatin or placebo (80 mg anytime within 18 hours before surgery) followed by a maintenance dose of 40 mg, started at least 12 hours after surgery, and 40 mg daily for 7 days
The results of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography IV (DECREASE-IV) randomized controlled trial[16] demonstrated that patients who had an intermediate cardiovascular disease risk—which was defined by an estimated risk of perioperative cardiac death and myocardial infarction of 1 to 6% by using clinical data and type of surgery—and who were randomly assigned to fluvastatin experienced a lower incidence of the end point than those randomly assigned to fluvastatin-control therapy (3.2% versus 4.9% events; hazard ratio 0.65, 95% confidence interval [CI] 0.35–1.10), but statistical significance was not reached (P = 0.17)
Summary
Many patients undergoing surgery take medicines used to prevent atherothrombotic cardiovascular events. Cardiovascular complications, including myocardial infarction, acute congestive heart failure, atrial fibrillation, fatal ventricular arrhythmia, and cardiac death, were found in up to 5% of patients undergoing in-hospital non-cardiac surgery[2,3]. Large prospective cohort studies have shown that the incidence of primary myocardial injury following non-cardiac surgery (MINS) ranges between 8 and 19% and that myocardial infarction accounts for about 40% of myocardial injury[5,6,7]. In this respect, cardiovascular risk assessment and optimization of medical therapy play important roles for risk reduction of adverse complications of non-cardiac surgeries[8]. We discuss evidence-based data concerning the continued use of statins in the perioperative period
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