Perioperative Statin Therapy Guidelines

Introduction to Statin Continuation

The American College of Cardiology recommends that patients currently taking statins and scheduled for noncardiac surgery should continue statin therapy to reduce the risk of major adverse cardiovascular events (MACE) 1, 2, 3
Patients already on statin therapy should continue taking their medication throughout the perioperative period, as discontinuation may lead to increased cardiovascular risk 4, 5

Statins have pleiotropic effects beyond lipid-lowering, including coronary plaque stabilization, decreased vascular inflammation, and improved endothelial function, which are particularly beneficial during the perioperative stress period 6, 7
A large US cohort study (n=780,591) showed that patients receiving perioperative lipid-lowering therapy had lower surgical mortality compared to those who did not receive such therapy 3
Discontinuation of statins before surgery may lead to a rebound effect that could be disadvantageous to patients 6

Statins reduce the risk of perioperative cardiac events, particularly in vascular surgery patients 5, 8
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 5, 8
For patients with or at risk of ischemic heart disease, statins provide important secondary prevention benefits that should not be interrupted for surgery 6, 7

For patients undergoing cardiac surgery with cardiopulmonary bypass, it should be considered to continue statin therapy at the current dose 9
For patients already on atorvastatin, continue the medication on the day of surgery and throughout the perioperative period 1, 3
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 6

If oral administration is not possible immediately after surgery, resume statin therapy as soon as the patient can take oral medications 4
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 6

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend continuing statin therapy in patients who are already taking statins and undergoing non-cardiac or cardiac surgery, including valve replacement surgery 10, 11

Continuing statin therapy during the perioperative period is associated with a reduction in major adverse cardiovascular events 10

For patients already taking statins, the medication should be continued on the day of surgery and throughout the perioperative period 10

The AHA/ACC guidelines for managing patients with valvular heart disease specifically mention that statin therapy is not indicated for preventing the hemodynamic progression of aortic stenosis in patients with mild to moderate calcified valvular disease (stages B to D) 12
However, this recommendation refers specifically to the use of statins for preventing the progression of aortic stenosis, not their use for secondary prevention of cardiovascular events in patients who already have an indication for statins 12
For patients with concurrent coronary disease, which is common in patients with valvular disease, all patients should be evaluated and treated for hypercholesterolemia using guidelines for primary and secondary prevention of coronary disease 12