How to manage a 72-year-old patient on atorvastatin (atorvastatin) with elevated liver enzymes, specifically alkaline phosphatase, Serum Glutamic-Oxaloacetic Transaminase (SGOT), and Serum Glutamic-Pyruvic Transaminase (SGPT), prior to a scheduled Coronary Angiography (CAG)?

Management of Elevated Liver Enzymes in a 72-Year-Old Patient on Atorvastatin Prior to Coronary Angiography

The coronary angiography should proceed as scheduled since the liver enzyme elevations are mild and already improving while continuing the statin therapy. 1, 2

Assessment of Current Liver Enzyme Elevations

The patient presents with the following liver enzyme values:

• Initial elevations:

  • Alkaline phosphatase: 289 U/L
  • SGOT (AST): 53 U/L
  • SGPT (ALT): 73 U/L

• Follow-up values (11 days later, still on statin):

  • Alkaline phosphatase: 193 U/L (↓33%)
  • SGOT (AST): 44 U/L (↓17%)
  • SGPT (ALT): 53 U/L (↓27%)

These findings represent:

1. Mild transaminase elevations (<2× upper limit of normal)
2. Spontaneous improvement while continuing statin therapy
3. Mixed pattern with predominant cholestatic features (elevated alkaline phosphatase)

Management Algorithm

Step 1: Risk Assessment

• The liver enzyme elevations are mild (<3× ULN) 1
• Values are already improving without intervention 1
• The patient requires coronary angiography, indicating significant cardiovascular risk

Step 2: Management Decision

• Continue current atorvastatin therapy 1, 2
• Proceed with scheduled coronary angiography 3
• Monitor liver enzymes after the procedure (approximately 4-6 weeks)

Step 3: Post-Procedure Considerations

• If liver enzymes continue to normalize:
  • Continue current atorvastatin dose
  • Monitor liver enzymes at 3 months and then annually
• If liver enzymes worsen or plateau:
  • Consider dose reduction rather than switching statins 1
  • If cardiovascular risk is high and LDL targets aren't met with lower dose, consider adding ezetimibe 3

Rationale for Decision

1. Statin benefits outweigh risks: The cardiovascular benefits of continuing statin therapy prior to coronary angiography outweigh the risks of mild liver enzyme elevations 3

2. Transient nature of elevations: According to FDA labeling, increases in serum transaminases with atorvastatin typically appear soon after initiation, are often transient, and frequently resolve with continued therapy 2

3. Improving trend: The patient's liver enzymes are already improving while continuing the statin, suggesting a transient and self-resolving phenomenon 1

4. Procedural considerations: Discontinuing statins before coronary angiography could potentially increase cardiovascular risk 3

Important Caveats

• If the patient develops symptoms of liver injury (jaundice, right upper quadrant pain, fatigue), promptly discontinue atorvastatin 2

• Only decompensated cirrhosis or acute liver failure are absolute contraindications to statin therapy 1, 4

• Consider non-alcoholic fatty liver disease (NAFLD) as a potential underlying cause of baseline liver enzyme elevations, as it's common in patients requiring statins 1

• Patients who consume substantial quantities of alcohol may be at increased risk for hepatic injury with statins 2

• Approximately 2% of patients on statins show elevated liver enzymes, but data do not suggest these elevations are associated with permanent hepatotoxicity 3

By following this approach, you can balance the cardiovascular benefits of continuing statin therapy against the minimal risk posed by mild and improving liver enzyme elevations in this patient requiring coronary angiography.