Does atorvastatin (lipitor) 10mg daily reduce the incidence of stroke and myocardial infarction (heart attack) during surgery?

From the Guidelines

Atorvastatin 10mg daily has not been specifically proven to reduce the incidence of stroke and myocardial infarction during surgery, but the most recent and highest quality study suggests that statin therapy may reduce perioperative cardiovascular events. While statins like atorvastatin are well-established for long-term cardiovascular risk reduction in appropriate patients, their perioperative benefit specifically during surgery is less clear. Some observational studies suggest potential benefit from continuing statin therapy through the perioperative period for patients already taking statins, but starting a statin immediately before surgery solely to prevent surgical complications is not a standard recommendation. For patients already on atorvastatin for appropriate indications (such as hyperlipidemia or established cardiovascular disease), it's generally recommended to continue the medication through the perioperative period to avoid withdrawal effects, as suggested by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1.

The theoretical benefit of statins perioperatively relates to their pleiotropic effects beyond cholesterol lowering, including anti-inflammatory properties and endothelial function improvement, which might help stabilize existing plaques. However, for patients not already on statin therapy, initiating atorvastatin specifically for surgical risk reduction would not be considered standard practice without other indications for statin therapy. The 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery suggests that perioperative initiation of statins may be considered in patients with clinical indications according to guideline-directed medical therapy (GDMT) who are undergoing elevated-risk procedures 1.

Key points to consider:

• The most recent guideline recommends continuing statin therapy in patients already taking statins, but does not recommend starting statin therapy solely for surgical risk reduction without other indications 1.
• Statin therapy may reduce perioperative cardiovascular events, but the evidence is not strong enough to support its use as a standard practice for surgical risk reduction 1.
• The decision to initiate or continue statin therapy should be based on individual patient risk factors and clinical indications, rather than solely on the basis of surgical risk reduction.

In summary, while atorvastatin 10mg daily may not be specifically proven to reduce the incidence of stroke and myocardial infarction during surgery, the most recent and highest quality study suggests that statin therapy may reduce perioperative cardiovascular events, and its use should be considered on a case-by-case basis.

From the FDA Drug Label

In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium on fatal and non-fatal coronary heart disease was assessed in 10,305 patients with hypertension, 40 to 80 years of age. Atorvastatin calcium significantly reduced the rate of coronary events [either fatal coronary heart disease or non-fatal MI] with a relative risk reduction of 36% [(based on incidences of 1.9% for atorvastatin calcium vs. 3% for placebo), p=0. 0005]. Although the reduction of fatal and non-fatal strokes did not reach a pre-defined significance level (p=0.01), a favorable trend was observed with a 26% relative risk reduction (incidences of 1.7% for atorvastatin calcium and 2.3% for placebo). In the Collaborative Atorvastatin Diabetes Study (CARDS), the effect of atorvastatin calcium on cardiovascular disease (CVD) endpoints was assessed in 2,838 subjects with type 2 diabetes. Atorvastatin calcium significantly reduced the risk of stroke by 48% (21 events in the atorvastatin calcium group vs. 39 events in the placebo group), HR 0.52,95% CI (0.31,0.89) (p=0. 016) and reduced the risk of MI by 42% (38 events in the atorvastatin calcium group vs. 64 events in the placebo group), HR 0.58,95.1% CI (0.39,0.86) (p=0.007).

The answer to whether atorvastatin 10 mg daily reduces the incidence of stroke and myocardial infarction (heart attack) is:

• Myocardial Infarction (MI): Yes, atorvastatin 10 mg daily reduces the risk of MI by 36% in the ASCOT trial and by 42% in the CARDS trial.
• Stroke: Yes, atorvastatin 10 mg daily reduces the risk of stroke, with a favorable trend of 26% relative risk reduction in the ASCOT trial and a significant reduction of 48% in the CARDS trial. However, these studies were not conducted during surgery. Therefore, based on the provided information, no conclusion can be drawn about the effect of atorvastatin 10 mg daily on the incidence of stroke and myocardial infarction during surgery 2.

From the Research

Atorvastatin and Cardiovascular Events

• The efficacy of atorvastatin in reducing the incidence of stroke and myocardial infarction (heart attack) during surgery has been studied in various clinical trials 3, 4, 5, 6, 7.
• A study published in the Journal of Vascular Surgery found that short-term treatment with atorvastatin significantly reduces the incidence of major adverse cardiovascular events after vascular surgery 3.
• Another study published in the journal Drugs found that atorvastatin 10 mg/day reduced the relative risk of the composite primary endpoint (acute coronary heart disease events, coronary revascularisation, or stroke) by 37% in patients with diabetes mellitus 4.
• The SPARCL trial found that 80 mg of atorvastatin per day reduced the overall incidence of strokes and of cardiovascular events in patients with recent stroke or transient ischemic attack 5.

Atorvastatin Dosage and Cardiovascular Events

• The IDEAL and TNT trials demonstrated the preventive efficacy of atorvastatin in patients with stable coronary heart disease, with intensive atorvastatin therapy (80 mg/day) reducing the risk of nonfatal myocardial infarction by 17-22% 6.
• However, the question asks about atorvastatin 10 mg daily, which was found to be effective in reducing cardiovascular events in patients with diabetes mellitus 4.
• There is limited evidence specifically addressing the efficacy of atorvastatin 10 mg daily in reducing the incidence of stroke and myocardial infarction during surgery.

Combination Therapy and Cardiovascular Events

• A study published in the Annals of Thoracic Surgery found that the combination of statin and β-blockers conferred a protective effect for stroke after coronary artery bypass graft surgery, with an odds ratio of 0.377 7.
• This suggests that combination therapy may be more effective than atorvastatin alone in reducing the incidence of stroke and myocardial infarction during surgery.