Perioperative Statin After Major Noncardiac Surgery

Study Questions:

What is the association of early perioperative statin use with outcomes in a national cohort of veterans undergoing noncardiac surgery?

Methods:

This retrospective, observational cohort analysis included 180,478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016. Data on statin use on the day of or the day after surgery were collected. The main outcomes measures were all-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database.

Results:

A total of 180,478 eligible patients (95.6% men and 4.4% women; mean [standard deviation] age, 63.8 [11.6] years) underwent analysis, and 96,486 were included in the propensity score–matched cohort (96.3% men; 3.7% women; mean age, 65.9 [10.6] years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48,243 propensity score–matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk [RR], 0.82; 95% confidence interval [CI], 0.75-0.89; p < 0.001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (RR, 0.82; 95% CI, 0.79-0.86; p < 0.001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (RR, 0.73; 95% CI, 0.64-0.83) for cardiac complications.

Conclusions:

The authors concluded that early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications.

Perspective:

This observational cohort analysis reports that statin use on the day of and/or the day after noncardiac surgery was associated with lower 30-day all-cause mortality and reduction in a variety of postoperative complications (most notably cardiac), compared with nonuse. Current evidence supports a protective effect of statins in the perioperative period, and the data presented in this study suggest a benefit of statins even when these medications are first administered in the immediate perioperative period. Until additional data are available, one could consider using the American College of Cardiology/American Heart Association Pooled Cohort Equations Risk Calculator to choose which patients, in addition to those with established cardiovascular disease, would be candidates for statin therapy immediately before surgery.

Clinical Topics: Dyslipidemia, Prevention, Nonstatins, Novel Agents, Statins

Keywords: Cardiovascular Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Morbidity, Mortality, Neurosurgery, Perioperative Period, Postoperative Complications, Primary Prevention, Quality Improvement, Risk, Risk Reduction Behavior, Simvastatin, Surgical Procedures, Elective, Surgical Procedures, Operative, Thrombosis, Veterans


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