Continuing Atorvastatin Before Surgery
In patients currently taking statins and scheduled for noncardiac surgery, continuation of statin therapy is strongly recommended to reduce the risk of major adverse cardiovascular events (MACE). 1
Evidence for Statin Continuation
- Patients already on statin therapy should continue taking their medication throughout the perioperative period, as discontinuation may lead to increased cardiovascular risk 1
- Statins have pleiotropic effects beyond lipid-lowering, including coronary plaque stabilization, decreased vascular inflammation, and improved endothelial function, which are particularly beneficial during the perioperative stress period 1
- A large US cohort study (n=780,591) showed that patients receiving perioperative lipid-lowering therapy had lower surgical mortality compared to those who did not receive such therapy 1
- Discontinuation of statins before surgery may lead to a rebound effect that could be disadvantageous to patients 1
Benefits of Perioperative Statin Therapy
- Statins reduce the risk of perioperative cardiac events, particularly in vascular surgery patients 1
- A meta-analysis showed that preoperative statin therapy was associated with a 59% reduction in mortality risk after vascular surgery and a 44% reduction in overall mortality for noncardiac surgery 1
- In a randomized controlled trial of 100 patients undergoing vascular surgery, those receiving atorvastatin 20 mg daily had significantly fewer cardiac events (8%) compared to placebo (26%) at 6-month follow-up 2, 1
- For patients with or at risk of ischemic heart disease, statins provide important secondary prevention benefits that should not be interrupted for surgery 1
Special Considerations
- For patients undergoing cardiac surgery with cardiopulmonary bypass, it should be considered to continue statin therapy at the current dose 1
- It is not recommended to initiate statin therapy shortly before elective cardiac surgery with cardiopulmonary bypass due to the associated risk of acute kidney injury 1, 3
- For patients with chronic kidney disease who are statin-naïve, caution should be exercised when considering perioperative statin initiation 3
- Temporarily discontinue atorvastatin in patients experiencing acute conditions with high risk of developing renal failure secondary to rhabdomyolysis (e.g., sepsis, shock, severe hypovolemia) 4
Practical Recommendations
- For patients already on atorvastatin (Atrova), continue the medication on the day of surgery and throughout the perioperative period 1
- Statins with long half-lives or extended-release formulations (such as atorvastatin, rosuvastatin, or fluvastatin extended release) are preferred to bridge periods when oral administration may not be possible 1
- If oral administration is not possible immediately after surgery, resume statin therapy as soon as the patient can take oral medications 1
- Monitor for potential side effects such as myopathy, especially in patients with risk factors (age >65 years, uncontrolled hypothyroidism, renal impairment) 4
Common Pitfalls to Avoid
- Avoid discontinuing statin therapy before surgery due to unfounded concerns about perioperative complications 5
- The risk of statin-induced myopathy and rhabdomyolysis during the perioperative period is often overstated; no studies have demonstrated significant increases in these complications in surgical patients continuing statin therapy 1
- Do not initiate high-dose statin therapy immediately before surgery in statin-naïve patients, as this may increase the risk of adverse effects, particularly in those with renal impairment 3, 6
- Failure to restart statin therapy postoperatively may be the most serious complication, as this can increase cardiovascular risk 5
In summary, if you are currently taking Atrova 20 (atorvastatin), you should continue taking it before and after surgery to reduce your risk of perioperative cardiovascular events. The benefits of continuing statin therapy significantly outweigh the potential risks.