Should statin (HMG-CoA reductase inhibitor) therapy be continued in patients undergoing general anesthesia?

Statin Therapy During General Anesthesia

Statin therapy should be continued in patients undergoing general anesthesia. 1 The evidence strongly supports maintaining statin therapy throughout the perioperative period to reduce cardiovascular risk and improve outcomes.

Evidence-Based Rationale

The 2025 European Association for Cardio-Thoracic Surgery (EACTS) guidelines specifically recommend that statin therapy should be continued at the current dose during cardiac surgery with cardiopulmonary bypass (Class IIa recommendation, Level B evidence) 1. This recommendation is consistent with the 2014 ESC/ESA guidelines on non-cardiac surgery, which state that perioperative continuation of statins is recommended, with preference for statins that have a long half-life or extended-release formulation 1.

Similarly, the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management explicitly recommend continuing statins in patients currently taking them (Class I recommendation, Level B evidence) 1. This represents one of the strongest recommendations in perioperative medication management.

Benefits of Continuing Statin Therapy

Maintaining statin therapy during the perioperative period offers several important benefits:

1. Reduced mortality: Statin use is associated with a significant reduction in perioperative mortality in patients undergoing major vascular surgery (adjusted odds ratio 0.22) 2

2. Plaque stabilization: Beyond lipid-lowering effects, statins provide pleiotropic benefits including anti-inflammatory effects and coronary plaque stabilization during the perioperative stress period 3

3. Dose-dependent cardiovascular protection: Higher-dose statin regimens appear to provide greater cardiovascular protection after surgery 4

4. Reduced adverse events: Statin therapy is associated with a reduction in cardiovascular adverse events even in intermediate-risk non-cardiac, non-vascular surgery 5

Potential Concerns and Management

While there have been historical concerns about potential statin-related complications during surgery:

• Myopathy risk: Although statins can cause myopathy, this risk is rare and does not outweigh the cardiovascular benefits in most patients 1

• Renal function: Caution may be warranted in patients with impaired renal function, particularly when considering loading doses before surgery 6

• Drug interactions: Be aware of potential interactions between statins and anesthetic agents, though these are uncommon with modern anesthetic techniques

Special Considerations

• Cardiac surgery: The 2025 EACTS guidelines specifically note that while initiating statin therapy shortly before elective cardiac surgery is not recommended due to AKI risk (Class III recommendation), continuing existing statin therapy is beneficial 1

• Vascular surgery: Perioperative statin use is particularly beneficial for patients undergoing vascular surgery, with or without clinical risk factors 1

• Non-cardiac surgery: For patients undergoing intermediate-risk procedures with at least one clinical risk factor, statin therapy may be considered 1

Algorithm for Perioperative Statin Management

1. For patients already on statins:

   • Continue statin therapy at the current dose
   • Administer the statin dose on the morning of surgery
   • Resume statin therapy as soon as oral intake is permitted postoperatively

2. For patients not on statins:

   • Consider initiating statin therapy for patients undergoing vascular surgery (Class IIa recommendation) 1
   • May consider initiating statins for patients with clinical risk factors undergoing intermediate-risk procedures 1
   • Avoid initiating statins immediately before cardiac surgery with CPB due to AKI risk 1

Conclusion

The most recent and highest-quality evidence strongly supports continuing statin therapy during the perioperative period for patients undergoing general anesthesia. Discontinuation of statin therapy before surgery is not recommended and may actually increase cardiovascular risk 1, 6. The potential benefits of maintained statin therapy in reducing perioperative cardiovascular events and mortality clearly outweigh the rare risks of statin-related complications.