Can the dose of statins (HMG-CoA reductase inhibitors) be increased in a patient with atherosclerosis of the aorta if the low-density lipoprotein (LDL) level is below the target goal?

From the Guidelines

Increasing statin doses for patients with atherosclerosis of the aorta despite LDL levels below goal may be considered, as the 2024 ESC guidelines recommend statins for the reduction of growth and rupture of AAA 1. While LDL targets remain the primary guide for statin therapy, evidence suggests that patients with established atherosclerosis might benefit from more intensive statin therapy regardless of baseline LDL levels. For such patients, consider increasing to high-intensity statins like atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily. This approach is based on the understanding that statins have pleiotropic effects beyond LDL reduction, including anti-inflammatory properties and plaque stabilization that may help reduce cardiovascular events in patients with established atherosclerosis. Before increasing the dose, evaluate the patient's current statin tolerance, liver function, and muscle symptoms. Monitor for side effects after dose increases, particularly myalgias, and check liver enzymes and creatine kinase as needed. The decision should be individualized based on the patient's overall cardiovascular risk profile, comorbidities, and potential for statin-related adverse effects, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Key considerations include:

• The patient's current statin regimen and potential for dose escalation
• The presence of other cardiovascular risk factors and comorbidities
• The potential benefits of intensive statin therapy in reducing cardiovascular events and improving outcomes in patients with atherosclerosis of the aorta.

From the Research

Statin Dose Increase for Atherosclerosis of Aorta with LDL Below Goal

• The decision to increase statin dose in patients with atherosclerosis of the aorta but LDL levels below goal is complex and depends on various factors, including the patient's overall cardiovascular risk and the presence of other comorbidities 2.
• According to the study by 2, the relationship between LDL-C control and cardiovascular risk is not straightforward, and the use of potent statins at very low doses might be beneficial in overcoming patient statin reluctance.
• The study by 3 emphasizes the importance of lowering LDL-C to reduce cardiovascular risk, and suggests that proprotein convertase subtilisin/kexin type 9 inhibitors may be useful in achieving this goal in very high-risk patients.
• The study by 4 found that the attainment of LDL-C targets is largely suboptimal in very high-risk patients with established atherosclerotic cardiovascular disease, and that a high dose of statin was used in only 54.9% of patients.
• The use of statins in patients with atherosclerosis of the aorta is supported by the study by 5, which discusses the importance of statins in reducing plasma cholesterol levels and modulating lipid metabolism.
• However, the study by 6 found that statins have no significant effect on the progression of degenerative aortic stenosis, and that treatment with statins is not recommended in patients with valvular aortic stenosis and without conventional indications to lipid-lowering treatment.

Key Considerations

• The patient's overall cardiovascular risk and the presence of other comorbidities should be taken into account when deciding whether to increase statin dose 2, 3.
• The use of proprotein convertase subtilisin/kexin type 9 inhibitors may be beneficial in achieving LDL-C goals in very high-risk patients 3, 4.
• The attainment of LDL-C targets is largely suboptimal in very high-risk patients with established atherosclerotic cardiovascular disease, and a high dose of statin may be necessary to achieve these targets 4.