Should a statin be initiated in a 78-year-old male with hypercholesterolemia, hypertension (HTN), and erectile dysfunction, who has a high Framingham risk score?

From the Guidelines

A statin should be considered for this 78-year-old male with a high Framingham risk score of 51.5%, hypercholesterolemia, hypertension, and erectile dysfunction, as the benefits of reducing cardiovascular risk outweigh the potential risks. The patient's high Framingham risk score indicates significant cardiovascular risk, and statins have been shown to reduce cardiovascular events even in older adults 1. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol, in patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences 1. Some key points to consider when starting statin therapy in this patient include:

• Moderate to high-intensity statins like atorvastatin 20-40 mg daily or rosuvastatin 10-20 mg daily would be appropriate options.
• Before starting treatment, baseline liver function tests and creatine kinase levels should be checked.
• The patient should be monitored for muscle pain, which is a common side effect of statins.
• The potential for statins to worsen erectile dysfunction should be considered and monitored.
• A comprehensive approach should also include management of hypertension, lifestyle modifications such as diet and exercise, and possibly referral to a specialist for erectile dysfunction management if needed. It's also important to note that the 2018 cholesterol clinical practice guidelines recommend a clinician–patient risk discussion before starting statin therapy, which should include a review of major risk factors, the presence of risk-enhancing factors, the potential benefits of lifestyle and statin therapies, and patient preferences and values in shared decision-making 1.

From the FDA Drug Label

The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. Atorvastatin calcium significantly reduced the rate of major cardiovascular events (primary endpoint events) with a relative risk reduction of 37%, HR 0.63,95% CI (0.48,0.83) (p=0.001) An effect of atorvastatin calcium was seen regardless of age, sex, or baseline lipid levels. The overall risk reduction was consistent regardless of age (<65, ≥65) or sex.

The patient in question is a 78-year-old male with a Framingham risk score of 51.5, which indicates a high risk of cardiovascular events. Given the patient's hypercholesterolemia and hypertension (HTN), starting a statin such as atorvastatin may be beneficial in reducing the risk of major cardiovascular events.

• Key benefits of atorvastatin include:
  • Reduction in major cardiovascular events
  • Reduction in risk of stroke and myocardial infarction
• Considerations for this patient:
  • Age: while the studies included patients ≥65 years, the mean age was 62 years, and the patient in question is 78 years old
  • Erectile dysfunction: not directly addressed in the provided drug label Given the available information, it is reasonable to consider starting a statin in this patient, but the decision should be made on a case-by-case basis, taking into account the patient's overall health status and other individual factors 2.

From the Research

Patient Profile

• Age: 78 years old
• Male
• Framingham risk score: 51.5
• Hypercholesterolemia
• Hypertension (HTN)
• Erectile dysfunction

Statin Therapy Considerations

• The patient's high Framingham risk score and hypercholesterolemia indicate a need for aggressive lipid-lowering therapy 3, 4, 5, 6, 7
• Rosuvastatin has been shown to be effective in reducing low-density lipoprotein cholesterol (LDL-C) levels and improving lipid profiles in patients with hypercholesterolemia 3, 4, 5, 6, 7
• The patient's age and comorbidities (HTN and erectile dysfunction) should be considered when selecting a statin, as some statins may have more favorable side effect profiles than others

Potential Benefits of Statin Therapy

• Reduction in LDL-C levels and improvement in lipid profiles 3, 4, 5, 6, 7
• Decreased risk of cardiovascular events and mortality 5, 6, 7
• Potential benefits for patients with hypertension and erectile dysfunction, as statins may help improve endothelial function and reduce inflammation

Potential Risks and Considerations

• Side effects of statin therapy, such as muscle pain and liver enzyme elevations 3, 4, 5, 6, 7
• Potential interactions with other medications, such as blood thinners and certain antibiotics
• The need for regular monitoring of lipid profiles and liver function tests to minimize the risk of side effects

Statin Selection

• Rosuvastatin may be a suitable option for this patient, given its efficacy in reducing LDL-C levels and improving lipid profiles 3, 4, 5, 6, 7
• The patient's age and comorbidities should be considered when selecting a statin, and the potential benefits and risks of statin therapy should be carefully weighed 3, 4, 5, 6, 7