Does taking statins (HMG-CoA reductase inhibitors) before surgery reduce the risk of stroke and heart attack?

From the Guidelines

Taking statins before surgery is recommended to reduce the risk of stroke and heart attack, particularly in patients undergoing cardiac surgery or who have existing cardiovascular risk factors, as supported by the most recent guidelines 1. The protective effects of statins extend beyond cholesterol lowering and include anti-inflammatory properties, improved endothelial function, and plaque stabilization—all particularly important during the stress of surgery when inflammation and cardiovascular demands increase. These "pleiotropic" effects can help prevent perioperative cardiovascular complications. For patients already on statins, it's recommended to continue them through the perioperative period, as stated in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. For high-risk patients not already taking statins, starting therapy (such as atorvastatin 40mg or rosuvastatin 20mg daily) at least 2 weeks before elective surgery may be beneficial, according to the same guideline 1. Some key points to consider include:

• The benefit of statin therapy varies based on individual risk factors, type of surgery, and existing medical conditions.
• Patients may experience muscle pain or liver enzyme elevations with statins, so monitoring for side effects is important, especially in the perioperative period when patients are exposed to multiple medications.
• The most recent and highest quality study, the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline, provides the strongest evidence for the recommendations 1. Overall, the use of statins before surgery can be an effective strategy to reduce the risk of cardiovascular complications, and their continuation or initiation should be considered on a case-by-case basis, taking into account the individual patient's risk factors and medical history, as supported by the guideline 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD MI and stroke in adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD. Non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure, and angina in adults with clinically evident CHD.

The use of statins, such as atorvastatin, before surgery is not explicitly mentioned in the provided drug label as a means to reduce the risk of stroke and heart attack. However, the label does indicate that atorvastatin is used to reduce the risk of myocardial infarction and stroke in specific patient populations.

• The label does not provide direct information on the use of statins in the context of surgery.
• There is no explicit mention of the timing of statin administration in relation to surgical procedures.
• The primary focus of the label is on the long-term management of cholesterol levels and reduction of cardiovascular risk in patients with or without existing coronary heart disease. Therefore, based on the provided information, no conclusion can be drawn about the specific effect of taking statins before surgery on the risk of stroke and heart attack 2.

From the Research

Statin Therapy Before Surgery

• Statin medications have been found to be highly effective in primary and secondary stroke prevention among medically managed patients with cardiovascular disease 3, 4.
• The use of statins before surgery has been associated with a reduced incidence of perioperative mortality and morbidity in patients undergoing major vascular surgery 5, 6.
• Studies have shown that statin therapy is independently associated with a significant reduction in the odds of death and ischemic stroke or death among patients with symptomatic carotid disease 3, 4.

Reduction in Cardiovascular Morbidity

• Statin use has been found to reduce cardiovascular morbidity and improve outcomes after major vascular surgery 3, 4, 6.
• A study from Johns Hopkins Hospital demonstrated a threefold reduction in the rate of perioperative stroke and fivefold reduction of perioperative mortality among patients undergoing carotid endarterectomy (CEA) who were taking statins 3, 4.
• Another study found that statin therapy was associated with an almost threefold reduction in the risk of death in patients undergoing major vascular surgery and an almost twofold reduction in the risk of postoperative myocardial infarction 6.

Pleiotropic Effects of Statins

• The pleiotropic effects of statin medications, such as improving endothelial function and reducing inflammation, may be responsible for the clinical observations of reduced cardiovascular morbidity and mortality 3, 4.
• Further work is necessary to better elucidate these mechanisms and to determine the optimal agents, dosing, and timing of drug administration among patients undergoing carotid interventions 3, 4.

Perioperative Statin Use

• Perioperative statin use has been associated with reduced 30-day mortality in stented patients undergoing non-cardiac surgery who have previously been prescribed both beta blockers and statins 7.
• Maintaining statin therapy perioperatively is associated with reduced adverse postoperative outcomes, including death, myocardial infarction, stroke, and renal failure 6.