Statins and perioperative myocardial infarction. Mechanisms of action

The growing prevalence of atherosclerosis means that perioperative myocardial infarction (PMI) is a significant issue for the anesthesiologist. Perioperative revascularization (if indicated medically), beta blocker (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, also exhibit pleiotrophic effects anti-inflammatory effects, thereby stabilizing vulnerable plaque and improve functioning of the endothelium in atherosclerosis. These effects appear to reduce 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 while the second part discusses the pharmacology of statins and the mechanisms of how they may reduce PMI.