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Statins for Surgical Patients

Authors: Trevor M Williams, MD, MPH ; Alden H Harken, MDFaculty and Disclosures

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Abstract and Introduction

Abstract

Objective: To evaluate perioperative statin treatment, to explore the rapidly increasing body of literature on the pleiotropic effects of statins, and to suggest a rational strategy of perioperative risk reduction.
Summary of Background Data: Vascular, cerebrovascular, and cardiovascular complications are all too common in surgery. Although treatment with β-blockers is a well-established strategy for perioperative cardiac risk reduction, prophylaxis with statins enjoys a firm pathophysiologic basis.
Methods: A PubMed search for studies evaluating outcomes of statin treatment in surgical series was accomplished by evaluating all articles found with the keyword surgery and the MeSH term for statins hydroxymethylglutaryl-CoA reductase inhibitors. Studies where no outcome was relatable to statin treatment were excluded as were studies dealing primarily with transplant surgery. An overview of the medical literature on statin use and cardiac outcome was also performed. Basic science investigations elucidating the mechanisms and effects of statins that may reduce perioperative risk were included.
Results: The pharmacology and pleiotropic effects of statins are delineated. Multiple beneficial outcomes are elucidated and explored. Statins prescribed in the perioperative period appear beneficial though only one clinical trial is available from which to make clinical recommendations.
Conclusion: Evidence supports a rebound effect. Statin treatment should be instituted and must not be discontinued in surgical patients. Current literature suggests that statins are protective in the preoperative period.

Introduction

Statins inhibit the rate-limiting step in biosynthesis of cholesterol. Multiple epidemiological studies have persuasively correlated chronic statin use with a favorable decrease in cardiovascular events. In that cholesterol is a component of all cell membranes and its precursors affect major intracellular signaling pathways, it is intuitively appealing to predict that statins will have wide ranging impact on many surgically relevant organ/cellular systems. Traditionally, a statin is accepted as successful lipid-lowering therapy that reduces cardiovascular events over years. Recently, statins have been promoted as perioperative risk reduction strategies because of their short-term effects on endothelium-dependent vasodilation, coagulation, platelet aggregation, vascular plaque stability, and inflammation. Because perioperative myocardial infarctions (MI) occur equally from coronary stenosis and plaque rupture, statins are postulated to decrease perioperative cardiovascular complications. The purposes of this review are: (1) to explore the cardiovascular benefits of chronic statin use; (2) to examine the pharmacology of statins; (3) to explore the direct influence of statins on vasomotor activity and coagulation; (4) to delineate the influence of statins on inflammation, coronary plaque, and cardiomyocyte stability; (5) to explore statins as a perioperative risk reduction strategy; and (6) to acknowledge the potential complications of statin use.

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