Will atorvastatin (Lipitor) be continued after Coronary Artery Bypass Grafting (CABG)?

Continuation of Atorvastatin After CABG

Atorvastatin should absolutely be continued after coronary artery bypass grafting (CABG) surgery, as all patients undergoing CABG should receive statin therapy indefinitely unless contraindicated. 1

Evidence-Based Rationale for Continuing Atorvastatin

• All patients undergoing CABG should receive statin therapy unless contraindicated (Class I, Level of Evidence: A) 1
• Discontinuation of statin or other dyslipidemic therapy is specifically not recommended before or after CABG in patients without adverse reactions to therapy (Class III: HARM, Level of Evidence: B) 1
• An adequate dose of statin should be used to reduce LDL cholesterol to less than 100 mg/dL and to achieve at least a 30% lowering of LDL cholesterol (Class I, Level of Evidence: C) 1
• For very high-risk patients, it is reasonable to treat with statin therapy to lower the LDL cholesterol to less than 70 mg/dL (Class IIa, Level of Evidence: C) 1

Timing of Statin Therapy After CABG

• Statin therapy should be reinstituted postoperatively once the patient is stable 2
• For patients already on statin therapy before surgery, it should be continued without interruption 1
• For patients undergoing urgent or emergency CABG who are not taking a statin, it is reasonable to initiate high-dose statin therapy immediately (Class IIa, Level of Evidence: C) 1

Benefits of Statin Therapy After CABG

• Statins improve long-term clinical outcomes after CABG, with at least moderate-intensity statin use associated with significantly lower risk of 5-year major adverse cardiac and cerebrovascular events (MACCE) compared with no or low-intensity statin use 3
• Higher-moderate intensity (atorvastatin 20-mg equivalent) and high-intensity statin (atorvastatin ≥40-mg equivalent) showed significantly lower risks of MACCE than lower-moderate intensity statin group at 5 years after CABG 3
• Statins improve vein graft redox state by inhibiting vascular Rac1-mediated activation of NADPH-oxidase, which may contribute to improved graft patency 4

Optimal Dosing Considerations

• For most patients after CABG, at least a moderate-intensity statin (atorvastatin ≥10 mg) is recommended 3
• Higher-moderate or high-intensity statin (equivalent dose with atorvastatin ≥20 mg) was associated with significantly lower risk of MACCE among CABG patients who presented with acute coronary syndrome 3
• The use of higher doses of atorvastatin (80 mg) did not demonstrate additional protective effects compared to standard doses (40 mg) in terms of reducing myocardial injury markers after CABG surgery 5

Additional Post-CABG Medication Considerations

• Aspirin (100 mg to 325 mg daily) should be initiated within 6 hours postoperatively if not started preoperatively and continued indefinitely 1
• Beta blockers should be reinstituted as soon as possible after CABG in all patients without contraindications 1, 2
• ACE inhibitors and ARBs should be reinstituted postoperatively once the patient is stable 1, 2

Common Pitfalls to Avoid

• Discontinuing statin therapy before or after CABG is specifically classified as harmful (Class III: HARM) 1
• Using inadequate doses of statins that fail to achieve target LDL reductions of at least 30% 1
• Failing to reinitiate statin therapy promptly after surgery 2
• Not considering higher-intensity statin therapy for high-risk patients, particularly those who presented with acute coronary syndrome 3

In conclusion, atorvastatin therapy should definitely be continued after CABG surgery as part of the standard of care to reduce cardiovascular events and improve long-term outcomes.