Statin withdrawal after major noncardiac surgery: Risks, consequences, and preventative strategies

Abstract

BACKGROUND: A growing body of research suggests that statins improve perioperative cardiac outcomes by attenuating inflammation. Conversely, some studies suggest that withdrawal of statins after surgery results in an upsurge of inflammation and adverse cardiac outcomes. METHODS: We performed a literature search using multiple medical databases to examine the basic, clinical, and experimental evidence supporting the existence of a statin withdrawal state. Studies examining outcomes associated with statin withdrawal were narratively synthesized. RESULTS: Published evidence suggests that statin withdrawal is associated with worse cardiac outcomes in a variety of scenarios, including acute coronary syndrome, ischemic stroke, and surgery. Although certain reasons for postoperative statin cessation are difficult to avoid (eg, ileus after surgery), we posit that many perioperative clinicians may be unaware of the importance of statin resumption in a timely fashion. This lack of awareness translates into preventable harm and an opportunity for outcome improvement. We introduce innovative practices through which perioperative practitioners may prevent statin discontinuation. CONCLUSIONS: Ensuring the resumption of statins after surgery should become routine practice for perioperative providers. We highlight knowledge gaps and identify a research agenda aimed at better understanding this practice. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

3rd GUIDELINE FOR PERIOPERATIVE CARDIOVASCULAR EVALUATION OF THE BRAZILIAN SOCIETY OF CARDIOLOGY

“…The main reasons for statin withdrawal are as follows: postoperative ileus and inability to administer oral medications, hemodynamic instability, concern with the occurrence of side effects, and lack of awareness of the importance of maintaining statins. 307 …”

Anesthesia for Patients with Prior Stroke

“…55 Statins if started 2 weeks prior to surgery reduce incidence of perioperative cardiac events and stroke, whereas perioperative withdrawal of statins is associated with increased risk. 56,57 Ongoing β-blockers should be continued. 58 As intraoperative metoprolol is associated with a 3.3-fold increased risk of perioperative stroke, other β-blockers such as esmolol or labetalol are recommended for intraoperative reduction of heart rate.…”

Cerebral ischemia during surgery: an overview

“…However, institutional practices vary due to the complexity of this issue and the lack of universal guidelines. Statins initiated at least 2 weeks before the operation may reduce the perioperative stroke rate [ 32 - 34 ] . Patients taking statins preoperatively should continue taking them throughout the perioperative period.…”