What treatment is recommended for a 60-year-old male with elevated Lipoprotein(a) (Lp(a)) of 185, Apolipoprotein B (Apo B) of 115, High-Density Lipoprotein (HDL) of 60, and Low-Density Lipoprotein (LDL) of 132, with a Coronary Artery Calcium (CAC) score of 0?

From the Guidelines

For this 60-year-old male with elevated Lp(a) of 185 mg/dL, ApoB of 115 mg/dL, and LDL of 132 mg/dL, despite having a coronary calcium score of 0 and good HDL of 60 mg/dL, moderate-intensity statin therapy is recommended. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL, at a 10-year ASCVD risk of ≥7.5%, should start a moderate-intensity statin if a discussion of treatment options favors statin therapy. Although the patient's 10-year ASCVD risk is not explicitly stated, the presence of elevated Lp(a) and ApoB levels, which are risk-enhancing factors, favor initiation of statin therapy 1.

Starting with atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily would be appropriate, as these medications have been shown to reduce LDL-C levels by ≥30% 1. The elevated Lp(a) and ApoB levels indicate increased cardiovascular risk despite the reassuring calcium score. Statins won't lower Lp(a) but will reduce overall atherosclerotic risk by lowering LDL and ApoB. Lifestyle modifications should accompany medication, including a Mediterranean or DASH diet, regular aerobic exercise (150 minutes weekly), weight management, smoking cessation if applicable, and limiting alcohol consumption. After starting statin therapy, lipid levels should be rechecked in 4-12 weeks to assess response and adjust dosing if needed. While the calcium score of 0 suggests absence of calcified plaque, the elevated Lp(a) represents an independent risk factor for cardiovascular disease that warrants intervention to reduce overall risk.

Key considerations in this patient's management include:

• Monitoring for potential adverse effects of statin therapy, such as muscle pain or elevated liver enzymes
• Regular assessment of lipid levels to adjust statin dosing as needed
• Emphasis on lifestyle modifications to reduce overall cardiovascular risk
• Consideration of additional risk factors, such as family history or chronic inflammatory disorders, which may influence the decision to initiate or intensify statin therapy 1.

From the FDA Drug Label

Atorvastatin Calcium Tablets are indicated: To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD The recommended starting dosage of atorvastatin calcium is 10 mg to 20 mg once daily. The dosage range is 10 mg to 80 mg once daily. Patients who require reduction in LDL-C greater than 45% may be started at 40 mg once daily.

The patient has a coronary calcium score of 0, which indicates a low risk of coronary heart disease. However, the patient's LDL level is 132, which is elevated.

• Treatment Goal: Reduce LDL-C levels to reduce the risk of myocardial infarction, stroke, and other cardiovascular events.
• Recommended Treatment: Atorvastatin calcium tablets can be used to reduce LDL-C levels. The recommended starting dosage is 10 mg to 20 mg once daily.
• Clinical Decision: Considering the patient's elevated LDL level and low coronary calcium score, a conservative approach would be to start with a low dose of atorvastatin calcium, such as 10 mg once daily, and monitor LDL-C levels to adjust the dosage as necessary 2.

From the Research

Patient Profile

• Age: 60 years old
• Male
• Lipid profile:
  • Lp(a): 185
  • Apo B: 115
  • HDL: 60
  • LDL: 132
• Coronary calcium score: 0

Treatment Recommendations

Based on the provided evidence, the following treatment recommendations can be considered:

• According to 3, a coronary calcium score of 0 is associated with a significantly lower risk of atherosclerotic cardiovascular disease (ASCVD) events. However, this does not necessarily mean that treatment is not required.
• The American College of Cardiology and the American Heart Association guidelines recommend treatment of patients with severe hypercholesterolemia (LDL-C ≥190 mg/100 ml) with a high-intensity statin 3.
• However, the patient's LDL-C level is 132, which is below the threshold for severe hypercholesterolemia.
• The study 4 suggests that high-dose statin therapy can reduce small dense LDL and MDA-LDL, which are associated with an increased risk of CV events.
• Another study 5 compared the efficacy of rosuvastatin versus atorvastatin in patients with acute coronary syndrome and found that rosuvastatin 40 mg was more effective in lowering LDL cholesterol than atorvastatin 80 mg.
• The use of PCSK9 inhibitors, such as evolocumab and alirocumab, can also be considered for patients who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe 6.

Considerations for Treatment

• The patient's coronary calcium score of 0 suggests a lower risk of ASCVD events, but treatment may still be necessary to reduce the risk of CV events.
• The choice of statin and dose should be individualized based on the patient's lipid profile and other risk factors.
• The use of PCSK9 inhibitors may be considered for patients who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe.
• Shared decision making between the patient and clinician is important to determine the best course of treatment 7.