Reducing perioperative cardiac complications: statins
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Review of 2 metaanalyses of RCTs on the effects of statins in the perioperative period. Watch my YouTube video describing these slides: http://youtu.be/wHYlf26AH00
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Reducing perioperative cardiac complications: statins
- 1. Reducing Perioperative Cardiac Risk: Statins Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine
- 2. Devereaux PJ et al., CMAJ 2005; 173:627
- 3. Cochrane Review: Statins in Vascular Surgery Data Review Through July 2012 All-cause Mortality Nonfatal MI
- 4. Effect of Perioperative Statins on Death, MI, Afib, and LOS: A Systematic Review Arch Surg 2012;147:181nonvasc, noncardiac vascular
- 6. • Statins should be continued in patients currently taking statins (I) • Reasonable to give statins in patients undergoing vascular surgery (IIa) • Consider statins in patients with ≥ 1 risk factor undergoing intermediate or high risk procedures (IIb) Current ACC/AHA 2014 Recommendations
Editor's Notes
- These PowerPoints are one of a series of PowerPoints on interventions that might reduce perioperative cardiac risk. These will focus on the research data on statins.
- This figure shows the pathophysiological cascade thought to explain perioperative myocardial infarction. On the far left surgery is shown to induce an inflammatory state with increased inflammatory markers (TNF, IL-1, IL-6, and CRP). Statins have been shown in CAD models to reduce these same inflammatory mediators. Thus it makes sense that if statins can reduce these mediators they should be able to reduce perioperative MIs. Lets see if the data bears that out.
- This is a systematic review published in 2013 by the Cochrane group. This is a state of the art systematic review done by the world’s experts in systematic reviews. Thus you can trust the methodology used. The systematic review was limited to RCTs of statins done in vascular surgery patients. As seen in the top figure statins seemed to reduce all cause mortality but it did not reach statistical significance (see dark black diamond). Likewise in the bottom figure statins seemed to reduce nonfatal MI but it did not reach statistical significance. I think clinically important reductions are contained in these confidence intervals. It should be noted that the data is limited by few studies with small sample sizes and few events)
- Chopra and colleagues published this systematic review in the Archives of Surgery in 2012. They looked at more varied surgeries (vascular, orthopedic, ENT, abdominal, and cardiac) than the Cochrane review and looked at broader outcomes. What you can see is that statins significantly reduced myocardial infarctions (top left), atrial fibrillation (middle left) and hospital length of stay (Top right) compared to placebo. There was a suggestion or reduced death (bottom left) but this did not reach statistical significance. I highlighted in yellow the nonvascular, noncardiac surgery studies and in blue the vascular surgery studies. Nonhighlighted studies are cardiac surgery studies. One could argue that the combination of so many varied surgical procedures together is a flaw of this metaanalysis.
- This is an observational study by Lindenauer and colleagues using hospital discharge and pharmacy records of over 780,000 patients to examine the association between lipid lowering therapy and in-hospital mortality following noncardiac surgery. There are important limitations to this study including not knowing when lipid lowering therapy was initiated. Patients who were on lipid-lowering therapy (defined as use during the 1st 2 days of hospitalization) had significantly lower odds ratios of in-hospital mortality compared to a propensity matched control group not on lipid lowering therapy. The lower figure shows NNT estimates stratified by RRCI scores. As expected the higher the risk the lower the NNT.
- These are the current recommendations by the ACC on prescribing statins perioperatively. Studies are currently ongoing in this area. It will be interesting to see when larger studies are completed if the recommendations on statin usage change. Also with the recently released cholesterol management guidelines I suspect more patients will be on statins anyway.