Do you hold HMG-CoA reductase inhibitors (statins) before surgery?

Perioperative Statin Management

Statins should be continued throughout the perioperative period in patients who are already taking them and scheduled for surgery. 1, 2

Evidence Supporting Statin Continuation

• For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued as a Class I recommendation with Level of Evidence B 1
• Discontinuation of statins before surgery may lead to a rebound effect with increased risk of cardiac morbidity, with one study showing statin withdrawal for 4 days before vascular surgery was associated with 2.9 times higher odds of cardiac morbidity 1
• Statins have pleiotropic effects beyond lipid-lowering, including coronary plaque stabilization, decreased vascular inflammation, and improved endothelial function, which are particularly beneficial during perioperative stress 2

Recommendations Based on Surgery Type

• For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable (Class IIa, Level of Evidence B) 1
• For patients with at least one clinical risk factor undergoing intermediate-risk procedures, statins may be considered (Class IIb, Level of Evidence C) 1
• For patients undergoing renal transplantation who are taking statin therapy, it is recommended that statin treatment be continued perioperatively and postoperatively (Class I, Level of Evidence B) 1

Perioperative Benefits of Statins

• 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, 2
• Statins reduce the risk of perioperative cardiac events, particularly in vascular surgery patients 2
• Continuing statin therapy during the perioperative period is associated with a reduction in major adverse cardiovascular events 2

Practical Administration Considerations

• If oral administration is not possible immediately after surgery, resume statin therapy as soon as the patient can take oral medications 2
• For patients already on atorvastatin, continue the medication on the day of surgery and throughout the perioperative period 2
• 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 2

Safety Considerations

• 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 2
• Pravastatin therapy should be temporarily withheld in any patient experiencing an acute or serious condition predisposing to the development of renal failure secondary to rhabdomyolysis (e.g., sepsis, hypotension, major surgery, trauma, severe metabolic disorders) 3
• Monitor for signs of myopathy, defined as muscle aching or weakness with CPK values greater than 10 times the upper limit of normal 3

Special Populations

• For patients undergoing cardiac surgery with cardiopulmonary bypass, statins should be continued at the current dose 2, 4
• For patients with unequivocal evidence of atherosclerosis undergoing renal transplantation, it is reasonable to initiate low- to moderate-dose statin therapy preoperatively and continue treatment postoperatively (Class IIa, Level of Evidence B) 1

The evidence strongly supports continuing statin therapy in the perioperative period for patients already taking these medications, with potential benefits for reducing cardiovascular events and mortality outweighing the risks.