In a patient with established atherosclerotic cardiovascular disease, diabetes, or high 10‑year cardiovascular risk who develops an acute illness such as infection, heart‑failure exacerbation, or is recovering from surgery, should I continue the statin therapy?

Continuation of Statin Therapy During Acute Medical Illness

Continue statin therapy without interruption in patients with established ASCVD, diabetes, or high cardiovascular risk who develop acute illness, infection, heart failure exacerbation, or are recovering from surgery. 1, 2, 3

Evidence Supporting Continuation

• The 2024 International Lipid Expert Panel explicitly states that statins should be continued perioperatively and during acute illness, as cardiovascular benefits outweigh theoretical perioperative risks. 1

• The 2025 American Diabetes Association guidelines emphasize that diabetic patients over 75 years already on statin therapy should continue treatment regardless of acute medical status, as the absolute cardiovascular benefit is greater in older adults due to higher baseline risk. 2

• Meta-analyses demonstrate that each 39 mg/dL reduction in LDL cholesterol yields a 9% reduction in all-cause mortality and 13% reduction in vascular mortality in patients with diabetes and ASCVD, with benefits maintained across all clinical contexts. 1, 3

Specific Clinical Scenarios

Post-Acute Coronary Syndrome or Established ASCVD

• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) must be continued or initiated immediately in all patients ≤75 years with clinical ASCVD, regardless of acute illness status. 1

• For patients >75 years with established ASCVD, continuation of existing statin therapy is reasonable and recommended even during acute medical events. 1, 2

• The 2024 ILEP discharge letter protocol mandates explicit instructions to continue statins during and after hospitalization, with escalation plans if LDL-C targets are not met. 1

Diabetic Patients During Acute Illness

• All diabetic patients aged 40-75 years on at least moderate-intensity statin therapy should continue treatment during infection, heart failure exacerbation, or surgical recovery. 1, 3

• For diabetic patients with multiple ASCVD risk factors, high-intensity statin therapy should be maintained to achieve ≥50% LDL-C reduction and target <70 mg/dL, even during acute illness. 1, 3

• The cardiovascular mortality benefit of statins in diabetic patients is linearly related to LDL-C reduction without a lower threshold, making continuation during acute illness critical. 3

Perioperative Management

• The ACC/AHA guidelines recommend continuation of statin therapy perioperatively for patients undergoing surgery, as the cardiovascular benefits outweigh any theoretical perioperative risks. 2

• If the patient is already on statin therapy before surgery, continuation through the perioperative period is reasonable and recommended. 2

• Statins should not be discontinued perioperatively unless severe acute illness develops that would contraindicate all oral medications. 2

Critical Pitfalls to Avoid

• Do not discontinue statins based solely on acute illness or hospitalization – even brief discontinuation leads to atherosclerotic plaque destabilization and increased cardiovascular events. 4, 5

• Do not withhold statins during infection or inflammatory states – the anti-inflammatory and pleiotropic effects of statins may provide additional benefit during acute illness. 6

• Do not reduce statin intensity during acute illness "to reduce pill burden" – the absolute cardiovascular risk is highest during and immediately after acute medical events, making continuation essential. 1, 4

• Do not use age >75 years as a reason to discontinue statins during acute illness – elderly patients derive the greatest absolute benefit from lipid-lowering therapy due to higher baseline cardiovascular risk. 2, 3

Monitoring During Acute Illness

• Continue the established statin regimen at the same dose and intensity unless specific contraindications develop (e.g., rhabdomyolysis, severe hepatotoxicity with ALT >3× ULN). 6

• If the patient cannot take oral medications temporarily, resume statin therapy as soon as oral intake is restored, without dose reduction. 1

• Reassess lipid panel 4-12 weeks after resolution of acute illness to ensure LDL-C targets remain achieved. 1, 7

Evidence on Discontinuation Harm

• Statin discontinuation, even briefly, is associated with severe adverse cardiovascular events due to atherosclerotic plaque destabilization and loss of pleiotropic anti-inflammatory effects. 4, 5

• Real-world data show that nonadherence to guideline-directed statin therapy results in significantly higher incident ASCVD events and mortality (hazard ratio 1.27 for high-risk patients not receiving statins versus those on guideline-directed therapy). 8

• The risk of serious statin-induced adverse events (rhabdomyolysis <0.1%, hepatotoxicity ≈0.001%) is far lower than the cardiovascular mortality benefit, making continuation during acute illness the safer strategy. 6