Jones & Bartlett Learning Medicine Blog

Perioperative statin therapy has long been felt to confer cardiac protection during both cardiac surgery and major noncardiac surgery.  Until recently the data have been scarce to definitively make claims in support of this belief.  In 2004, Durazzo et al. conducted the first randomized trial examining the use of Perioperative statins in major noncardiac surgery.  They compared the use of atorvastatin 20 mg daily compared against placebo initiated 2 weeks prior to elective major vascular surgery and continued for 45 days post-operatively.  The investigators found that statins were associated with a 70% relative risk reduction of the combined end-point of death, nonfatal MI, unstable angina, or stroke. [1] Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. [2]

Statins are thought to be beneficial for a myriad reasons:

• They lower lipids and have additional pleiotropic effects.
• The cardioprotective effects of statins during the perioperative period is more likely related to their pleiotropic effects than their lipid-lowering effects.
• Statins inhibit the action of HMG-CoA Reductase which is the rate-limiting step in cholesterol synthesis, but effective lipid lowering takes months.
• Perioperative studies have demonstrated that statins confer a cardioprotective benefit when started even 1-2 weeks in advance of major surgery.
• These pleiotropic effects of statins include suppression of endothelial nitric oxide which promotes coronary vasodilation.
• Statins also reduce lipopolysaccharide-induced tissue factor release, decrease plasminogen activator inhibitor levels, and increase tissue plasminogen activator; the combination of which reduces coronary thrombosis.
• Statins also have anti-inflammatory properties which may provide more plaque stability. [3]

Dr. Joseph Esherick Monthly Blog - May 2011

Initiation of statins during the acute period has been shown to be beneficial during an acute coronary syndrome and immediately following an ischemic stroke. ^[1,2,3] It is believed that statins, HMG-CoA reductase inhibitors, have pleiotropic properties that have anti-inflammatory effects, improve endothelial function and inhibit the body’s thrombogenic response.  The properties are in addition to the lipid lowering effects of statins.  These pleiotropic effects are felt to be the principal mechanism by which statins decrease recurrent cardiovascular and cerebrovascular events when started acutely during an acute coronary syndrome or immediately after an ischemic stroke.  Statins have also been shown in two randomized controlled trials to decrease the incidence of peri-procedural myocardial infarction if started soon before percutaneous coronary intervention or before major vascular surgery. ^[4,5]

Dr. Joseph Esherick Monthly Blog - April 2011

The leading cause of death in the United States is cardiovascular mortality.  Therefore, the early identification and appropriate management of acute coronary syndrome is essential for all hospital-based physicians.  The American College of Cardiology Foundation and the American Heart Association have recently updated their practice guidelines on the management of patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI)¹.

This blog will focus on the primary changes in the management of non-ST-elevation acute coronary syndrome.  The Level 1 recommendations are that patients with definite UA/NSTEMI at medium to high risk should receive 325 mg of aspirin and a second antiplatelet agent on presentation.  Dual antiplatelets should be given regardless of whether an invasive or conservative strategy is chosen.  The second antiplatelet agent could be either a loading dose of clopidogrel, prasugrel, or a GP IIb/IIIa inhibitor (preferably eptifibatide or tirofiban).  The major change in the recommendations is that dual antiplatelet therapy is now routinely recommended upstream of percutaneous coronary intervention (PCI).  In patients undergoing PCI, both aspirin and a thienopyridine, clopidogrel or prasugrel, should be continued for at least 12 months.  For those treated conservatively, dual antiplatelet therapy should continue for at least 1 month and ideally for 1 year.