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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Narcis Hudorovic Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Hudorovic, N. PubMed Articles by Hudorovic, N. Related Collections Education Lung - transplantation Cardiac - pharmacology Cardiac - physiology

Letters to the Editor

Statins and perioperative management of patients undergoing cardiovascular surgery

Narcis Hudorovi^_*

Department of Endo and Vascular Surgery, University Hospital "Sestre Milosrdnice", Vinogradska 29, 10000 Zagreb, Croatia

Received 16 January 2008; accepted 25 January 2008.

^_* Corresponding author. Tel.: +385 1 46 40 774; fax: +385 1 38 62 292. (Email: narcis.hudorovic{at}zg.htnet.hr).

Key Words: Cardiovascular disease • Risk factors • Statins

The extraordinary actuality of the article of Paraskevas [1] is my excuse for this letter. Patients presenting for major cardiovascular surgery represent a dynamic challenge for the surgeon that extends beyond the intricacies of the planned operation. These patients frequently suffer from other significant comorbidities such as diabetes, respiratory, renal disease and elevated cholesterol. The management of these patients has to address not only immediate perioperative management issues but also prevent the deterioration of coexisting disease.

The growing body of evidence for such patients confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves the quality of life for these patients. In such patients, controversy remains regarding the optimal dose of aspirin with/without statins or clopidogrel to prevent postoperative complications.

While offering the advantage of being easily available at medium cost, statin therapy is a preventive measure of subclinical atherosclerosis, but at the same time it is not a predictive factor of postoperative cardiovascular events.

There are a number of recent studies, unfortunately the author citied only one, that suggest statin therapy may reduce the risk of perioperative complications [2–4]. This evidence, whilst promising, is not conclusive. Many of these studies are small and the data collected over a long period during which practices have changed significantly. This is an area in which the results of large randomized control trials are required to guide therapy.

Furthermore, data from medical patients suggest that the withdrawal of statin therapy may itself be associated with adverse consequences.

For that reason and the purposes of possible world-wide comparisons of recent studies representing data, serum cholesterol in patients with cardiovascular diseases should be evaluated and treated according to guidelines of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Interestingly cessation of statins pre-event was associated with significantly poorer outcomes when compared to those patients who continued on statin therapy or those who had never been on a statin. Moreover, for the real-world practice it is important to be cautious in extrapolating from medical to surgical patients but these data mitigate against withdrawing statins from patients undergoing cardiovascular surgery.

The doubtful conclusion offered by the author that statins should become an essential component of the therapeutic approach of the cardiovascular patients is mainly based on retrospective or small studies. Nevertheless, no definitive evidence has been proved and this conclusion needs to be confirmed by a multicenter, prospective randomized trial.

If the main feature of the article had to be emphasized in a title and speaks for itself [5] two statements could or must be emphasized. Patients presenting for cardiovascular surgery have a complex array of medical problems. The careful management of these problems can improve outcome for these patients and is part of the fascination of this speciality. The cardiovascular teams are asked to address pre-, peri- and postoperative management issues relating not solely but predominantly to the statins in combination with scoring systems, beta-blockers, anti-platelet therapy, etc.

Put simply there is more to cardiovascular surgery than cardiovascular surgery.

References

1. Paraskevas KI. Applications of statins in cardiothoracic surgery: more than just lipid-lowering. Eur J Cardiothorac Surg 2008;33:377-390.[Abstract/Free Full Text]
2. Durazzo AF, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004;39:967-975.[CrossRef][Medline]
3. Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B. Improved postoperative outcomes associated with preoperative statin therapy. Anesthesiology 2006;105:1260-1272.[CrossRef][Medline]
4. Poldermans D, Bax JJ, Kertai, MD, Krenning B, Westerhout CM, Schinkel AF. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation 2003;107:1848-1851.[CrossRef][Medline]
5. Joint British recommendations on prevention of coronary heart disease in clinical practice. British Cardiac Society, British Hyperlipidemia Association, British Hypertension Society, endorsed by the British Diabetic Association. Heart 1998;80:21–9.

This article has been cited by other articles:

				K. I. Paraskevas Reply to HudorovicWould a randomized controlled trial testing the effects of statins on patients undergoing cardiothoracic surgery be ethical? Eur. J. Cardiothorac. Surg., May 1, 2008; 33(5): 948 - 948. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Narcis Hudorovic Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Hudorovic, N. PubMed Articles by Hudorovic, N. Related Collections Education Lung - transplantation Cardiac - pharmacology Cardiac - physiology