Statins and perioperative myocardial infarction

The growing prevalence of atherosclerosis means that perioperative myocardial infarction (PMI) is of significant concern to anesthesiologists. Perioperative revascularization (if indicated medically), beta blockade (in high risk patients) and statin therapy are therapeutic modalities that are currently employed to reduce PMI. Statins not only lower low density lipoprotein levels but, via their actions on the isoprene pathway, exhibit pleiotropic effects. Statins stabilize vulnerable plaque, predominantly via their anti-inflammatory effects, and improve the functioning of the endothelium in atherosclerosis. These effects appear to reduce the perioperative complications of atherosclerotic lesions. It is important to have an understanding of newer developments in the pathophysiology of atherosclerosis to be able to appreciate the mechanisms of action of statins. The focus has changed from identification of stenotic coronary lesions to the identification of vulnerable plaque. This review is divided into 2 parts. The first part focuses on the pathophysiology of atherosclerosis. The second part will be published in a later issue and will discuss the pharmacology of statins and the mechanisms whereby they may reduce the incidence of PMI.