Several observational studies have suggested that 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor therapy administered at the time of noncardiac surgery is associated with a reduction in major adverse events. In a retrospective review of more than 750,000 operations performed at 329 hospitals, Lindenauer and colleagues noted that patients who were receiving lipid-lowering therapy at surgery (which included stains in 91% of cases) demonstrated a 30% relative reduction in all-cause hospital mortality (2.13% vs. 3.05%; P < .001), and the benefits of lipid-lowering therapy appeared to be greatest among higher-risk patients.23 Likewise, Poldermans and asso ciates, in a case-control study involving patients who underwent major vascular surgery at a single center, noted an independent, greater than fourfold reduction in perioperative mortality among patients receiving statins at the time of surgery.24 In another analysis of patients who underwent open abdominal aortic aneurysm repair, statin use was associated with significant reductions in adjusted 30-day death or MI (3.7% vs. 11.0%), in late (median, 4.7 years) all-cause mortality (18% vs. 50%), and in cardiac mortality (11% vs. 34%).25
These provocative findings require confirmation in a randomized controlled trial before firm treatment recommendations are possible. However, most patients undergoing vascular surgery already possess indications for chronic statin therapy for the prevention of cardiac events, and among patients already receiving treatment it seems reasonable to continue statin therapy through the perioperative course. Potential mechanisms by which statins may reduce perioperative cardiac complications relate to the plaque-stabilizing effects of these agents, including their anti-inflammatory and antithrombotic properties, and their beneficial influences on plaque-related endothelial dysfunction. Whereas P-blockers exert their primary cardioprotective effects through their influence on myocardial oxygen supply and demand, the principal effect of statins in the perioperative period may be related to the prevention of atherosclerotic plaque rupture. These two forms of therapy may therefore be especially complementary, a hypothesis that is currently being evaluated in the prospective DECREASE-IV study, in which a combination of fluvastatin and bisoprolol therapy is being examined in the perioperative setting.26,27
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