Can the dose of statins (HMG-CoA reductase inhibitors) be increased in a patient with atherosclerosis of the aorta and normal Low-Density Lipoprotein (LDL) levels?

From the Guidelines

Increasing statin doses is recommended for patients with atherosclerosis of the aorta, even with normal LDL levels, to achieve an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. This approach is supported by the concept that patients with established atherosclerotic disease often benefit from more intensive statin therapy regardless of baseline lipid levels.

• High-intensity statins like atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily would typically be recommended for such patients.
• Moderate-intensity options include atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, or pravastatin 40-80 mg daily. The decision to increase statin intensity should be individualized based on the patient's overall cardiovascular risk, comorbidities, and potential for side effects.
• Statins work beyond simply lowering LDL by stabilizing plaques, reducing inflammation, and improving endothelial function, which explains their benefit even when LDL appears normal, as highlighted in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1. Regular monitoring for muscle symptoms, liver function abnormalities, and potential drug interactions is essential when increasing statin intensity.
• The goal is to reduce the risk of cardiovascular events by addressing the underlying atherosclerotic disease process rather than focusing solely on LDL numbers. In patients who do not achieve their LDL-C goal on maximally tolerated statins, treatment with a PCSK9 inhibitor is recommended to achieve target values, as stated in the 2024 ESC guidelines 1.
• Additionally, a combination of statins and ezetimibe is indicated in patients with atherosclerotic PAAD to achieve the given target values.

From the FDA Drug Label

To reduce LDL-C and slow the progression of atherosclerosis in adults. Rosuvastatin was assessed by B-mode ultrasonography in patients with elevated LDL-C, at low risk (Framingham risk <10% over ten years) for symptomatic coronary artery disease and with subclinical atherosclerosis as evidenced by carotid intimal-medial thickness (cIMT).

The decision to increase the statin dose in a patient with atherosclerosis of the aorta but normal LDL levels cannot be directly supported by the provided drug labels. The labels discuss the use of rosuvastatin in reducing LDL-C and slowing the progression of atherosclerosis, but they do not provide guidance on dose adjustment in patients with normal LDL levels. Key points:

• The labels do not address the specific scenario of a patient with atherosclerosis of the aorta and normal LDL levels.
• The labels discuss the use of rosuvastatin in reducing LDL-C and slowing the progression of atherosclerosis, but do not provide guidance on dose adjustment in patients with normal LDL levels.
• No conclusion can be drawn from the provided information regarding the decision to increase the statin dose in this patient population 2, 2.

From the Research

Statins Dose Increase for Atherosclerosis of Aorta with Normal LDL

• The decision to increase the statins dose for a patient with atherosclerosis of the aorta but normal LDL levels is complex and depends on various factors, including the patient's overall cardiovascular risk and the specific characteristics of their atherosclerosis 3.
• Studies have shown that statins can be effective in reducing the progression of atherosclerosis, even in patients with normal LDL levels, by reducing inflammation and improving endothelial function 4, 5.
• However, the effectiveness of statins in reducing the progression of atherosclerosis may depend on the dose and potency of the statin, as well as the individual patient's response to treatment 3, 5.
• Some studies have suggested that higher doses of statins may be more effective in reducing the progression of atherosclerosis, particularly in patients with high-risk features such as atherosclerosis of the aorta 5.
• On the other hand, other studies have raised questions about the potential benefits and risks of increasing statins dose in patients with normal LDL levels, particularly in terms of the potential for increased side effects and interactions with other medications 6, 7.

Considerations for Increasing Statins Dose

• When considering increasing the statins dose for a patient with atherosclerosis of the aorta but normal LDL levels, healthcare providers should carefully weigh the potential benefits and risks of treatment, taking into account the individual patient's characteristics and medical history 3, 4.
• Factors to consider include the patient's overall cardiovascular risk, the severity and extent of their atherosclerosis, and their response to previous treatment with statins or other lipid-lowering therapies 3, 5.
• Healthcare providers should also consider alternative treatment options, such as other lipid-lowering therapies or lifestyle modifications, and discuss the potential benefits and risks of these options with the patient 4, 7.