Can an adult without severe liver disease, recent statin‑associated muscle injury, or inability to take oral medication continue taking atorvastatin (Lipitor) before surgery?

Can You Take Atorvastatin Before Surgery?

Yes, you should continue taking atorvastatin before surgery—stopping it increases your risk of cardiac complications and death. 1

Primary Recommendation: Continue Atorvastatin Perioperatively

The 2024 AHA/ACC guidelines provide a Class I recommendation (highest level) that patients currently on statins scheduled for noncardiac surgery must continue statin therapy to reduce the risk of major adverse cardiac events (MACE). 1

Evidence Supporting Continuation

• Withdrawal of statins 4 days before vascular surgery increases cardiac morbidity by 2.9-fold, demonstrating that stopping atorvastatin is more dangerous than continuing it 1

• Multiple guidelines from the ACC/AHA (2014 and 2024), European Heart Journal (2009), and AHA/ACC transplant guidelines (2012) all provide Class I recommendations to continue statins perioperatively 1

• Atorvastatin specifically has a long half-life, making it ideal for bridging the immediate post-operative period when oral intake may not be feasible 1

Critical Safety Considerations

When Atorvastatin Should Be Used With Caution

Patients with severe liver disease (acute liver failure or decompensated cirrhosis) should NOT take atorvastatin, as this is an absolute contraindication per FDA labeling 2

In patients with chronic kidney disease (eGFR <60 mL/min/1.73 m²) who are statin-naïve, initiating high-dose atorvastatin immediately before surgery may increase acute kidney injury risk, particularly with loading doses 3

The Myopathy Concern Is Largely Theoretical

• Despite widespread concern about perioperative statin-induced rhabdomyolysis, no published studies support this risk except isolated case reports 1

• A retrospective study of 981 consecutive vascular surgery patients found no cases of rhabdomyolysis, significantly elevated creatine kinase, or increased myopathy in statin users 1

• The perioperative environment (renal impairment, multiple drugs, analgesics masking symptoms) theoretically increases myopathy risk, but this has not materialized in clinical practice 1

Specific Clinical Scenarios

For Patients Already Taking Atorvastatin

Continue your current dose through the day of surgery and throughout the perioperative period without interruption 1

• Take your morning dose on the day of surgery 4
• Resume immediately when oral intake is possible postoperatively 1
• Do not skip doses due to concerns about drug interactions with anesthesia 1

For Statin-Naïve Patients Considering Starting Atorvastatin

The 2024 AHA/ACC guidelines recommend initiating statins preoperatively in patients who meet criteria based on ASCVD history or 10-year risk assessment, with intention of long-term use (Class I recommendation) 1

However, avoid high-dose loading strategies in statin-naïve patients with chronic kidney disease, as this increased acute kidney injury in a randomized trial 3

For High-Risk Surgical Populations

Vascular surgery patients derive particular benefit from continuing atorvastatin, with randomized trials showing:

• 8% cardiac event rate with atorvastatin vs. 26% with placebo at 6 months (P=0.03) 1
• Significant reduction in perioperative cardiovascular complications when started 30 days before surgery 1

Renal transplant patients taking statins should continue therapy perioperatively and postoperatively (Class I recommendation) 1

Common Pitfalls to Avoid

Do Not Stop Atorvastatin Due to:

• Concerns about intraoperative hypotension—the risks of withdrawal exceed continuation risks 4
• Fear of drug interactions with anesthesia—no evidence supports this concern 1
• Inability to take oral medications immediately postoperatively—atorvastatin's long half-life provides coverage 1
• Theoretical myopathy risk—clinical evidence does not support routine discontinuation 1

Special Consideration for Liver Transplant Patients

For liver transplant candidates, pravastatin is preferred over atorvastatin due to interactions with calcineurin inhibitors (CNIs), though patients already on atorvastatin should continue it perioperatively 1

Drug Interaction Alert

If you are prescribed Paxlovid (nirmatrelvir/ritonavir) perioperatively, atorvastatin dose may need adjustment or temporary substitution with pravastatin or fluvastatin, as ritonavir is a strong CYP3A inhibitor that increases atorvastatin levels and myopathy risk 5

Bottom Line Algorithm

1. Currently taking atorvastatin + no severe liver disease → Continue through surgery 1
2. Currently taking atorvastatin + acute liver failure or decompensated cirrhosis → Contraindicated, discuss alternatives 2
3. Statin-naïve + meets ASCVD criteria + normal kidney function → Consider starting with intention of long-term use 1
4. Statin-naïve + chronic kidney disease → Avoid high-dose loading; use standard doses if initiated 3