Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Abstract

BackgroundThe effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome.MethodsElectronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility.ResultsWe included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30–0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70–1.24], p = 0.61) (psubgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00–1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71–3.26], p = 0.28) (psubgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03–13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic.ConclusionsPerioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.Electronic supplementary materialThe online version of this article (10.1186/s13613-018-0441-3) contains supplementary material, which is available to authorized users.

Preoperative endothelial dysfunction in cutaneous microcirculation is associated with postoperative organ injury after cardiac surgery using extracorporeal circulation: a prospective cohort study

“…Preoperative statin therapy was not associated with a significantly different time to reach the peak during iontophoresis of ACh. This result is consistent with previous studies that found neutral or detrimental effects of statins in cardiac surgery particularly about the kidney outcomes [ 36 ]. In the same way, despite the detrimental effect of atrial fibrillation, a chronic beta-blocker therapy was not associated with a decrease in organ dysfunction or a shorter time to reach the peak during iontophoresis of ACh [ 37 ].…”

Atrial fibrillation in cardiac surgery

“…Statins had a protective effect against myocardial infarction in patients with non-cardiac procedures (2.3% in the statin group vs. 5.1% in the control group; OR, 0.44; CI 95%, 0.30-0.64), with a number needed to treat of 35. However, there was no effect on mortality, myocardial infarction or embolic episodes in the group of cardiac intervention 44 . The authors suggest that statin consumption is considered part of AFACS prophylactic treatment in case of contraindication for treatments of greater effectiveness, especially in coronary artery bypass graft and aortic valve replacement procedures.…”

­­Statins in the perioperative period

“…Results from a meta-analysis of prospective observational studies provided conflicting evidence 23 . A comparison of studies is complicated by varying outcome definitions, types of surgery, and preoperative versus perioperative statin use.…”