Should a patient with high lifetime ASCVD risk, elevated LDL, and stage 2 hypertension on amlodipine 2.5 mg increase amlodipine to 5 mg or add a statin?

From the Guidelines

For a patient under age 40 with a lifetime ASCVD risk of 69%, total cholesterol between 180-200 mg/dL, LDL > 120 mg/dL, blood pressure averaging 143/90 mmHg, and currently taking amlodipine 2.5 mg, the next best step would be to add a statin. Given the patient's remarkably high lifetime ASCVD risk and elevated LDL cholesterol, the initiation of statin therapy is warranted to reduce cardiovascular risk, as emphasized by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. The patient's LDL level > 120 mg/dL and lifetime ASCVD risk of 69% indicate a need for aggressive management of cholesterol levels to mitigate the risk of future cardiovascular events. Key considerations include:

• The patient's age and high lifetime ASCVD risk, which necessitate early intervention to modify risk factors and prevent future cardiovascular events.
• The elevated LDL cholesterol level, which is a major risk factor for ASCVD and should be addressed through pharmacological therapy, specifically with a statin, as recommended by the guideline 1.
• The importance of lifestyle modifications, including a heart-healthy diet, regular exercise, and sodium restriction, to complement pharmacological interventions and reduce cardiovascular risk.
• The need for ongoing monitoring of the patient's response to statin therapy, including assessment of side effects and liver function, as well as regular follow-up to adjust the treatment plan as needed. The guideline recommends starting with a moderate-intensity statin for primary prevention in adults with LDL-C levels ≥ 70 mg/dL and a 10-year ASCVD risk ≥ 7.5% 1. In this case, adding a statin, such as atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily, would be the most appropriate next step to reduce the patient's cardiovascular risk. While increasing the amlodipine dose to 5 mg daily may be considered to further lower blood pressure, the primary focus should be on initiating statin therapy to address the patient's elevated LDL cholesterol and high lifetime ASCVD risk.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Profile

• Lifetime ASCVD risk: 69%
• Age: under 40
• Total Cholesterol (TC): 180-200
• Low-Density Lipoprotein (LDL): > 120
• Average Systolic/Diastolic Blood Pressure (SBP/DBP): 143/90
• Current medication: amlodipine 2.5 mg

Treatment Options

• Raising amlodipine to 5 mg daily
• Adding a statin

Considerations

• According to 2, 3, 4, statins are the primary pharmacologic intervention for ASCVD risk reduction and have proven efficacy and safety in reducing cardiovascular events and total mortality.
• The patient's high LDL level (> 120) and lifetime ASCVD risk (69%) indicate a need for aggressive lipid management 2, 4.
• Adding a statin may be a more effective approach than raising the amlodipine dose, as statins have been shown to reduce LDL levels and ASCVD risk 2, 3, 4.
• However, the patient's age (under 40) and relatively low TC level (180-200) may need to be considered when deciding on the best treatment approach.

Potential Next Steps

• Consider adding a statin to the patient's treatment regimen to reduce LDL levels and ASCVD risk 2, 3, 4.
• Evaluate the patient's response to the added statin and adjust the treatment plan as needed.
• If the patient is unable to tolerate a statin or requires additional lipid-lowering therapy, consider alternative options such as ezetimibe or PCSK9 inhibitors 2, 5, 6.