Perioperative Management of Atorvastatin
Atorvastatin should be continued on the morning of surgery for patients already taking this medication. 1
Evidence-Based Rationale
The American College of Cardiology/American Heart Association guidelines strongly recommend that for patients currently taking statins and scheduled for noncardiac surgery, continuation of statin therapy is recommended (Class I, Level of Evidence B-NR) to reduce the risk of major adverse cardiovascular events 1. This recommendation is consistent across multiple guidelines.
Benefits of Continuing Atorvastatin Perioperatively
Cardiovascular Protection: Statins provide significant cardiovascular protection during the perioperative period by:
- Improving endothelial function
- Reducing vascular inflammation
- Stabilizing atherosclerotic plaque 1
Mortality Reduction: Meta-analyses have shown that perioperative statin therapy is associated with a 44% reduction in mortality for noncardiac surgery and a 59% reduction for vascular surgery 1
Rebound Risk: Discontinuation of statins may cause a rebound effect that could be disadvantageous for surgical patients 1
Pharmacokinetic Considerations
Atorvastatin has favorable pharmacokinetic properties that make it suitable for continuation through the perioperative period:
- Half-life: Approximately 7 hours 2
- Extended duration of action: Atorvastatin is considered a long-acting statin 3
- Bioavailability: While oral bioavailability is only 14% due to first-pass metabolism, this doesn't affect the recommendation to continue therapy 2
Practical Administration Guidelines
For patients already on atorvastatin:
- Take the regular dose on the morning of surgery
- Resume normal dosing as soon as oral intake is possible postoperatively
For statin-naïve patients:
- The LOAD trial did not demonstrate a reduction in major cardiovascular complications with short-term perioperative statin therapy in statin-naïve patients 4
- However, if a patient meets criteria for long-term statin therapy based on ASCVD history or risk assessment, perioperative initiation is recommended with intention for long-term use 1
Special Considerations
Potential Concerns
While there are theoretical concerns about statin-induced myopathy during surgery, evidence does not support this as a significant risk:
A retrospective study of 981 consecutive vascular surgery patients found no cases of rhabdomyolysis, significantly higher creatine kinase levels, or increased incidence of myopathy in statin users 1
The FDA label for atorvastatin recommends temporary discontinuation "in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis" 5, but routine surgery does not typically meet this threshold
Monitoring Recommendations
- Monitor for signs of myopathy postoperatively (muscle pain, tenderness, or weakness)
- Consider checking creatine kinase levels if symptoms develop
- Ensure adequate hydration perioperatively
Conclusion
The weight of evidence strongly supports continuing atorvastatin on the morning of surgery. The cardiovascular protective effects outweigh the theoretical risks, and discontinuation could potentially lead to adverse cardiovascular outcomes. This recommendation aligns with current ACC/AHA guidelines and is supported by multiple observational studies and meta-analyses.