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Original Investigation
February 2017

Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery

Author Affiliations
  • 1Department of Anesthesia and Perioperative Care, University of California, San Francisco
  • 2Department of Anesthesia and Perioperative Care, Department of Veterans Affairs Medical Center, San Francisco, California
  • 3Cardiology Section, Department of Medicine, Department of Veterans Affairs Medical Center, Denver, Colorado
  • 4Center for Medication Safety, Pharmacy Benefits Management Services, Department of Veterans Affairs Medical Center, Hines, Illinois
  • 5Department of Biostatistics, University of Colorado, Denver
  • 6Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS) and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
JAMA Intern Med. 2017;177(2):231-242. doi:10.1001/jamainternmed.2016.8005
Key Points

Question  Is exposure to a statin in the early perioperative period associated with reduced postoperative complications after noncardiac surgery?

Findings  This observational cohort analysis of veterans linked risk and outcome data from the Veterans Affairs Surgical Quality Improvement Program database to statin prescriptions in 180 478 patients and evaluated the associations of early statin exposure on 30-day mortality. After adjustment for risk, other medications used, and potential selection biases, 30-day mortality was significantly reduced in the statin-exposed group.

Meaning  Perioperative statin use may be beneficial in reducing 30-day mortality, although the effects of selection biases cannot be excluded.


Importance  The efficacy of statins in reducing perioperative cardiovascular and other organ system complications in patients undergoing noncardiac surgery remains controversial. Owing to a paucity of randomized clinical trials, analyses of large databases may facilitate informed hypothesis generation and more efficient trial design.

Objective  To evaluate associations of early perioperative statin use with outcomes in a national cohort of veterans undergoing noncardiac surgery.

Design, Setting, and Participants  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.

Exposure  Statin use on the day of or the day after surgery.

Main Outcomes and Measures  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 [SD] 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 [SD] 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, 0.82; 95% CI, 0.75-0.89; P < .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 (relative risk, 0.82; 95% CI, 0.79-0.86; P < .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 (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications.

Conclusions and Relevance  Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered.