Statin Therapy before Cardiac Surgery: Neutral or Detrimental Effects?

We read the interesting large retrospective study by Komatsu et al. on preoperative chronic statin use in patients undergoing coronary artery bypass grafting, valve surgery, or combined procedures.¹  Chronic statin therapy was associated with no significant difference in prolonged mechanical ventilation, pneumonia, in-hospital mortality, neurologic outcome, and length of intensive care unit or hospital stay,¹  suggesting neutral effects on postoperative clinical outcome.

It would be interesting to know the incidence of acute kidney injury after surgery in the study by Komatsu et al.¹  It is well known that postoperative acute kidney injury is crucial in patients’ postoperative course and is associated with higher mortality rate.²  Two large, high-quality, randomized placebo-controlled trials were recently published, respectively, in the New England Journal of Medicine and JAMA. Zheng et al.³  randomly assigned 1,922 cardiac surgery patients to receive perioperative rosuvastatin or placebo, started 1 to 8 days before surgery, and the authors found that perioperative statins did not prevent postoperative atrial fibrillation or perioperative myocardial damage, but acute kidney injury was more common in patients receiving rosuvastatin. Billings et al.⁴  randomized 617 patients to high-dose perioperative atorvastatin or placebo, started the day before surgery, and found increased acute kidney injury in statin-naive patients with chronic kidney disease. A recent systematic review and meta-analysis of randomized controlled trials with low risk of bias found that perioperative statin therapy was associated with an increased incidence of postoperative acute kidney injury as compared with placebo, with 314 of 1,318 patients (23.82%) in the statin group having acute kidney injury versus 262 of 1,319 patients (19.86%) in the placebo group (odds ratio 1.26 [95% CI, 1.05 to 1.52]; P = 0.01).⁵  Notably, a trend toward increased mortality was noted in the statin group: 9 of 1,318 (0.68%) patients died in the statin group versus 2 of 1,319 (0.15%) in the placebo group (odds ratio 1.26 [95% CI, 1.05 to 1.52]; P = 0.06).⁵  Since the trials included in the meta-analysis randomized patients to a short course of preoperative statin regimen (between 1 and 7 days), we would like to ask Komatsu et al. for further data regarding length of preoperative statin therapy and, if available, a stratification according to it (e.g., short-term vs. long-term statins administration).

In conclusion, there is growing high-quality evidence^3–5  that suggests not administering statins in the days before cardiac surgery. Statins in the days before cardiac surgery are not only unuseful, as also suggested by the observational study of Komatsu et al.,¹  but are harmful to renal function,^2–4  and a detrimental effect on survival could not be excluded.⁴  There is compelling need for further large, high-quality, randomized placebo-controlled trials to confirm these findings and to assess the most appropriate time-point of statin discontinuation before cardiac surgery.

The authors declare no competing interests.