Should a patient on statin therapy for primary or secondary cardiovascular prevention continue the statin during an acute illness or infection?

Should Statins Be Discontinued During Acute Illness?

No—statins should be continued during acute illness, particularly during acute coronary syndromes, infections, and critical illness, as discontinuation is associated with worse cardiovascular outcomes and increased mortality. 1, 2

Evidence Against Discontinuation

Acute Coronary Syndromes and Cardiovascular Events

• Discontinuing statins during acute coronary syndrome (ACS) hospitalization is associated with increased short-term mortality and major adverse cardiac events. 1
• Observational data from the NRMI-4 registry and PRISM study demonstrate harm when statins are suddenly stopped after an ACS event. 3
• Patients already on statin therapy at the time of ACS presentation should never have their statin discontinued. 1

Critical Illness and Sepsis

• Statin discontinuation during conditions of severe acute vascular stress (sepsis, shock, major surgery, trauma) must be contraindicated. 2
• In a prospective randomized trial of patients with hemispheric ischemic stroke, stopping statins for just 3 days was associated with a 4.7-fold increase in risk of death or dependency, greater neurological deterioration, and larger infarct volume. 2
• Prior statin therapy is associated with a 13-fold reduction in the relative risk of developing severe sepsis (RR 0.13,95% CI 0.03-0.52) and a 70% reduction in ICU admission risk (RR 0.30,95% CI 0.1-0.95). 4

Post-Operative Period

• Discontinuing statins during the post-operative period following major vascular surgery is associated with higher incidence of myocardial ischemia, non-fatal myocardial infarction, and cardiovascular death. 2

When Temporary Discontinuation May Be Considered

Specific High-Risk Scenarios (FDA Guidance)

The FDA label for pravastatin (representative of statin class warnings) states that temporary discontinuation should only occur in patients experiencing acute conditions at high risk of developing renal failure secondary to rhabdomyolysis, specifically: 5

• Sepsis with severe hypovolemia
• Shock
• Major surgery or trauma
• Severe metabolic, endocrine, or electrolyte disorders
• Uncontrolled epilepsy

However, this recommendation conflicts with the stronger evidence showing harm from discontinuation during these exact conditions. 2, 4 The balance favors continuation in most cases unless active rhabdomyolysis is present.

Active Hepatic Failure

• Statins are contraindicated in patients with acute liver failure or decompensated cirrhosis. 5
• If serious hepatic injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs, promptly discontinue. 5

Confirmed Rhabdomyolysis

• Discontinue statins if markedly elevated CK levels occur (>10× ULN with muscle symptoms) or if myopathy/rhabdomyolysis is diagnosed. 5

Clinical Algorithm for Statin Management During Illness

Step 1: Assess Current Statin Status

• If patient is already on a statin: Continue the current dose unless contraindications develop. 1, 2
• If not on a statin but presenting with ACS: Initiate high-intensity statin (atorvastatin 80 mg or rosuvastatin 20-40 mg) within 24 hours. 6, 1

Step 2: Monitor for Absolute Contraindications

Check for:

• Active rhabdomyolysis (CK >10× ULN with muscle symptoms) 5
• Acute liver failure or decompensated cirrhosis 5
• Unexplained persistent hepatic transaminase elevations 5

If any present: Discontinue statin temporarily until resolved.

Step 3: Assess Relative Risk Factors

In patients with severe acute illness (sepsis, shock, major trauma), weigh:

• Risk of statin withdrawal syndrome (4.7-fold increased mortality in stroke, increased ACS events) 2, 3
• versus theoretical risk of rhabdomyolysis in setting of renal hypoperfusion 5

Clinical decision: Continue statin in most cases, with close CK monitoring if renal function deteriorating. 2, 4

Step 4: Optimize Adherence Strategy

• Initiate statins before hospital discharge rather than deferring to outpatient setting—patients started before discharge are much more likely to achieve long-term adherence and LDL targets. 1
• Document statin continuation plan clearly in discharge summary. 3

Common Pitfalls to Avoid

The "Polypharmacy Deprescription" Error

• Do not deprescribe statins as part of medication reconciliation during acute illness—this practice is associated with worse outcomes. 3, 2
• Statins should be prioritized over many other cardiovascular medications during acute events. 3

The "Statin Holiday" Myth

• Annual "statin holidays" or routine dose reductions during illness are non-evidence-based practices that increase cardiovascular risk. 3
• Some practitioners incorrectly recommend these approaches due to unfounded concerns about adverse effects. 3

Misinterpreting Muscle Symptoms

• Most muscle symptoms during acute illness are due to the illness itself, not the statin (nocebo/drucebo effect). 7
• Do not reflexively discontinue statins for myalgias without checking CK levels. 5
• Only discontinue if CK >10× ULN with symptoms. 5

Special Populations

Stable Chronic Coronary Disease

• No increase in adverse outcomes has been observed following statin discontinuation in patients with stable chronic coronary artery disease (not acutely ill). 2
• This is the only scenario where discontinuation may be considered if truly necessary, but continuation is still preferred. 2

Hemodialysis Patients

• For patients on maintenance hemodialysis, evidence is insufficient to recommend initiating statins, but continuation of existing regimens is reasonable. 6
• Do not discontinue statins in dialysis patients during acute illness. 6