Stopping Statins for Vascular Surgery May Raise Risk

BY MITCHEL L. ZOLER

VIENNA -- Stopping a patient's statin regimen for a few days perioperative to major vascular surgery was linked with a significant rise in cardiovascular death, myocardial infarctions, and myocardial ischemia in a single center study of 298 patients.

A regular statin regimen may be stopped temporarily at the time of surgery because there is no intravenous statin formulation. Oral drugs often are halted for a few days at the time of major surgery.

"The pleiotropic effects of statins only last for a few hours or days, and that probably makes the difference in this study," Dr. Olaf Schouten said while presenting a poster at the annual congress of the European Society of Cardiology.

The results also indicated that patients using an extended-release statin formulation, specifically extended-release fluvastatin, had significantly fewer ischemic cardiac events than did patients treated with any of several conventional-release statins.

The implication is that patients who must stop a statin for surgery should restart the drug as soon as possible, said Dr. Schouten, a vascular surgeon at Erasmus Medical Center in Rotterdam, the Netherlands. The results also suggest that if stopping a statin for a few days is unavoidable, patients might fare better if they take an extended-release statin for several days before surgery starts and the regimen is stopped.

The study included 298 consecutive patients on long-term statin treatment who underwent major vascular surgery at Erasmus. About a quarter of the patients stopped treatment for an average of 3 days, with a range of 2 to 8 days; the other 75% maintained treatment during and after surgery. The most common formulation used was extended-release fluvastatin, used by 100 patients. Other formulations were simvastatin, atorvastatin, and pravastatin (see box).

Because statin treatment wasn't stopped randomly, Dr. Schouten and his associates used both multivariable and propensity-score analyses to control for other variables and to assess the impact of statin discontinuation.

Stopping a statin was associated with a 4.6-fold increased risk of troponin release, a marker of myocardial ischemia, and with a 7.5-fold increased risk of cardiovascular death or myocardial infarction. The analyses also showed that patients who stopped treatment with extended-release fluvastatin had significantly fewer events in the first 30 days after surgery than did patients treated with any type of immediate-release statin, including fewer deaths and myocardial infarctions as well as less troponin release (see box).

When asked to comment on this article, Dr. Russell H. Samson stated: "This is yet another example of how important statins are to the vascular patient irrespective of the patient's cholesterol levels. Clearly all our patients should always be on statins unless contraindicated by side effects or cross reactivity with other medications. At issue remains which statin is best? This study suggests long-acting fluvastatin may be more advantageous than other statins in the perioperative period. Fluvastatin is not as powerful in reducing LDL or raising HDL as some of the newer statins and these newer drugs do not require a long-acting formulation. Clearly a randomized study will be required."

Dr. Samson is a clinical associate professor of surgery at Florida State University and an associate editor of VASCULAR SPECIALIST.