Data from the prospective, international, cohort VISION study [Berwanger O et al. Eur Heart J. 2015] of patients undergoing noncardiac surgery have indicated the value of preoperative statin use to lessen cardiovascular (CV) complications, according to Otavio Berwanger, MD, Research Institute-Cardiac Hospital, São Paulo, Brazil.

Of the estimated 200 million adults worldwide who receive noncardiac surgery every year, ≥ 10 million experience CV complications within 30 days. Observational data and findings of small randomized controlled trials have implicated statin use before surgery in the reduced risk of such CV events. More robust data are needed, and the paucity of data was the impetus for the VISION study.

VISION was a 12-center, 8-country observational study. Consecutive patients ≥ 45 years old undergoing noncardiac surgery at the participating centers were enrolled. The total enrollment of over 40 000 yielded a cohort that was a representative sample of patients undergoing noncardiac surgery. Early findings from the first 15 478 patients linked postoperative elevated troponin with 30-day mortality in the patient population [Devereaux PJ et al. JAMA 2012].

Data from 7337 patients—2845 who received statin preoperatively and 4492 who did not—were presented. Baseline characteristics between the 2 groups were similar in the propensity-matched population, with the exception of slightly higher prevalence of coronary artery disease, peripheral vascular disease, diabetes, and the preoperative use of aspirin and angiotensin-converting enzyme/angiotensin II receptor blocker inhibitors among statin users.

The prevalence of urgent (2.2%), emergent (8%), orthopedic (about 26%), and low-risk (36%) surgery was similar between the 2 groups.

The primary outcome was all-cause mortality, myocardial injury after noncardiac surgery, or stroke at 30 days. Secondary outcomes included peak troponin related to myocardial ischemia, myocardial infarction, CV and non-CV death, and stroke. Subgroup analyses assessed the effects of statin on CV events at 30 days.

After propensity matching, preoperative use of statin was associated with a significantly lower risk at 30 days of the primary outcome (RR, 0.83; 95% CI, 0.73 to 0.95; P = .007). Secondary outcomes were also significantly lower with statin use, including all-cause mortality (RR, 0.58; 95% CI, 0.40 to 0.83; P = .003) and cardiovascular mortality (RR, 0.42; 95% CI, 0.23 to 0.76; P = .004).

The matched statin group had a lower risk of the primary outcome (RR, 0.82; 95% CI, 0.68 to 0.98). Survival at 30 days was also significantly greater in matched patients preoperatively treated with statins (HR, 0.57; 95% CI, 0.47 to 0.69; P = .004). Subgroup analyses revealed a potential preferential benefit of preoperative statin use in 1973 patients with diabetes relative to 5364 patients without diabetes (RR, 0.71; 95% CI, 0.56 to 0.91 vs RR, 0.92; 95% CI, 0.77 to 1.09; P_interaction = .04).

Limitations of VISION included its observational design (statin use clearly might be a surrogate for another confounder related to 30-day outcome when the associated risk for survival is substantially lower than the primary outcome), the presence of some baseline differences, and the lack of data on statin type/dose, liver function, and muscle function.

Nonetheless, the data from this large cohort of patients undergoing noncardiac surgery indicate the potential value of statin use before surgery in lessening CV complications 30 days postoperatively. Dr Berwanger noted that these findings need to be confirmed in large perioperative randomized controlled trials.