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Pre-surgery statins cut risk of cardiac events, but questions remain

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Giving statins before a surgery lowers the risk of heart attack in statin-naïve patients, according to a new meta-analysis.

The drugs also reduced the time patients spent at the hospital and cut the rate atrial fibrillation (AF) during cardiac surgery, researchers report in the February issue of the Archives of Surgery.

“These results suggest that perioperative practice and guidelines should be modified to incorporate greater use of statins in patients undergoing surgery,” Dr. Vineet Chopra of the University of Michigan Health System in Ann Arbor and colleagues write.

Cardiac complications remain a big problem in patients with cardiovascular risk factors who undergo high-risk surgery. According to the Dr. Chopra’s team, postoperative complications account for more than one in five preventable deaths and $9 billion in extra healthcare spending.

Statins are known to cut perioperative complications in people who already take the drugs, but it’s unclear whether statin-naïve patients reap the same benefits.

Dr. Chopra and his colleagues found 15 randomized controlled trials with a total of nearly 2,300 patients, none of whom had been on statin maintenance therapy before.

Eleven trials involved cardiac surgery, two involved vascular surgery and two were non-cardiac. The patients received statins at different doses, with therapy starting anywhere from two to 37 days before surgery and lasting between 3 and 67 days.

Based on 10 studies, 4.5% of 1,041 statin recipients suffered a perioperative heart attack, compared to 8.9% of the 1,036 control patients — a significant risk reduction (RR, 0.53). The effect was seen in both cardiac and non-cardiac surgery.

Nine studies reported AF complications, with statins leading to a significant risk reduction (RR, 0.56). Overall, 19.9% of 467 patients on the drugs developed AF versus 36.3% of 466 control patients.

Only trials involving cardiac surgery reported this outcome, however.

Finally, the length of hospital stay was significantly reduced in the statin group, although that effect disappeared when excluding the 11 trials involving cardiac surgery.

There were no differences in death rates and length of ICU stay between the two groups.

The researchers say perioperative statins might work by counteracting the vascular and inflammatory responses to surgery, which might otherwise overwhelm a heart with stenotic coronary artery disease.

Dr. Chopra received support from the Michigan Institute for Clinical and Health Research, and one of his co-authors has consulted for pharmaceutical companies.

In a commentary, Dr. David Spain of Stanford University in California notes that Dr. Chopra and colleagues do not mention postoperative complications or adverse events such as skeletal muscle problems or liver toxicity.

“Although rare, these complications can be serious,” Dr. Spain cautions. “Statins also downregulate the coagulation cascade and have been reported to increase blood loss in certain procedures.”

Based on the new report, Dr. Spain feels convinced the drugs should be given to statin-naive patients undergoing cardiac surgery, and probably major vascular procedures as well.

“But how we should apply these findings to noncardiac procedures is less clear to me,” he adds. “So, before we go adding statins to the drinking water or the perioperative checklist, I think we need some more data.”