Perioperative statin therapy in patients at high risk for cardiovascular morbidity undergoing surgery: a review

Abstract

Statins feature documented benefits for primary and secondary prevention of cardiovascular disease and are thought to improve perioperative outcomes in patients undergoing surgery. To assess the clinical outcomes of perioperative statin treatment in statin-naive patients undergoing surgery, a systematic review was performed. Studies were included if they met the following criteria: randomized controlled trials, patients aged ≥18 yr undergoing surgery, patients not already on long-term statin treatment, reported outcomes including at least one of the following: mortality, myocardial infarction, atrial fibrillation, stroke, and length of hospital stay. The following randomized clinical trials were excluded: retrospective studies, trials without surgical procedure, trials without an outcome of interest, studies with patients on statin therapy before operation, or papers not written in English. The literature search revealed 16 randomized controlled studies involving 2275 patients. Pooled results showed a significant reduction in (i) mortality [risk ratio (RR) 0.53, 95% confidence interval (CI) 0.30-0.94, P=0.03], (ii) myocardial infarction (RR 0.54, 95% CI 0.38-0.76, P<0.001), (iii) perioperative atrial fibrillation (RR 0.53, 95% CI 0.43-0.66, P<0.001), and (iv) length of hospital stay (days, mean difference -0.58, 95% CI -0.79 to -0.37, P<0.001) in patients treated with a statin. Subgroup analysis in patients undergoing non-cardiac surgery showed a decrease in the perioperative incidence of mortality and myocardial infarction. Consequently, anaesthetists should consider prescribing a standard-dose statin before operation to statin-naive patients undergoing cardiac surgery. However, there are insufficient data to support final recommendations on perioperative statin therapy for patients undergoing non-cardiac surgery.

Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process

“…In fact, the percentage of agreement was 55% for liberal transfusion strategy and only 42% for minimal extra corporeal circulation (MECC). One intervention (preoperative statin therapy in statin naïve patients) [49][50][51] was excluded after completion of the web vote because large high quality RCTs showing no benefit and possible harm were published thereafter. [52][53] Page 10 of 39…”

Inflammatory response and extracorporeal circulation

“…A recent review and meta-analysis provided by de Waal and colleagues demonstrated that preoperative initiation of statin administration reduces mortality, myocardial infarction, perioperative new-onset atrial fibrillation and length of hospital stay [76].…”

Prevention, epidemiology, and prognosis of perioperative ­myocardial injury

“…This may trigger plaque rupture and acute coro nary syndromes (ACS) perioperatively [33]. Thus, in an attempt to prevent MINS or major adverse cardiac events (MACE) in the perioperative setting, various agents including βblockers, α2adrenergic antagonists, statins and aspirin (acetylsalicylic acid, ASA) have been trialed to reduce the sympathetic response [8,34], stabilise coronary plaque [35] or to inhibit platelet function [8,36].…”