What is the management approach for a patient with a 10.6% risk of Atherosclerotic Cardiovascular Disease (ASCVD)?

From the Guidelines

For a patient with a 10.6% risk of Atherosclerotic Cardiovascular Disease (ASCVD), I recommend starting with lifestyle modifications and moderate-intensity statin therapy, such as atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily, as the primary approach to reduce ASCVD risk. This approach is based on the latest guidelines from the American College of Cardiology/American Heart Association 1, which emphasize the importance of lifestyle modifications and statin therapy in reducing ASCVD risk. The patient's 10.6% risk falls within the range of 7.5-20% 10-year risk, where moderate-intensity statins are recommended for primary prevention.

Key components of the management approach include:

• Lifestyle modifications, such as a Mediterranean or DASH diet, regular physical activity (150 minutes of moderate exercise weekly), smoking cessation, and weight management
• Moderate-intensity statin therapy, such as atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily
• Blood pressure control to <130/80mmHg using medications like ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics
• Consideration of aspirin 81mg daily for select high-risk patients without elevated bleeding risk
• Regular monitoring of lipid levels, blood pressure, and other risk factors, with follow-up every 3-6 months initially

The use of coronary artery calcium scoring (CACS) may also be considered in patients with borderline ASCVD risk, as it can provide guidance on the need for statin therapy 1. However, in this case, the patient's 10.6% risk is above the borderline threshold, and moderate-intensity statin therapy is recommended. Overall, this comprehensive approach targets the major modifiable risk factors that contribute to atherosclerosis, including dyslipidemia, hypertension, and inflammation, thereby reducing overall cardiovascular morbidity and mortality.

From the FDA Drug Label

The study population had an estimated baseline coronary heart disease risk of 11.6% over 10 years based on the Framingham risk criteria

• The patient's risk of Atherosclerotic Cardiovascular Disease (ASCVD) is 10.6%, which is close to the baseline risk in the JUPITER study.
• The JUPITER study showed that rosuvastatin significantly reduced the risk of major CV events with a statistically significant relative risk reduction of 44% and absolute risk reduction of 1.2% in patients with a similar risk profile.
• Based on this information, the management approach for a patient with a 10.6% risk of ASCVD could be to consider statin therapy, such as rosuvastatin, to reduce the risk of major CV events 2.

From the Research

Management Approach for a Patient with a 10.6% Risk of Atherosclerotic Cardiovascular Disease (ASCVD)

The management approach for a patient with a 10.6% risk of ASCVD involves the use of statin therapy as the first-line treatment. According to 3, statins are a major moderator of hepatic LDL cholesterol output, effectively reducing serum LDL cholesterol concentrations, in a dose-dependent manner.

Statin Therapy

• Statins are recommended as a first-line agent in all secondary prevention patients, as well as those in primary prevention at high or very high risk for ASCVD events 3.
• The potency and dose of statins should be tailored to the individual's cardiovascular risk and the tolerance to their potential adverse effects in order to achieve the guidelines-directed LDL goals 3.
• High-intensity statins, such as rosuvastatin 20-40 mg and atorvastatin 40-80 mg, are anticipated to reduce LDL-C by ≥50% 4.

Additional Therapies

• For patients who do not achieve adequate LDL-C reduction with statin therapy, additional therapies such as ezetimibe, PCSK9 inhibitors, or bempedoic acid may be considered 5.
• PCSK9-directed therapies, such as monoclonal antibodies (mAbs) or small interfering RNA (siRNA) therapies, may be recommended for higher-risk patients with established ASCVD or those with familial hypercholesterolemia 5.

Lifestyle Factors

• Lifestyle factors, such as diet and physical activity, remain an important part of ASCVD prevention 6.
• Factors such as poor adherence to statins, poor glycemic control, and inadequate physical activity may be associated with failing to achieve LDL-C targets 7.

Risk Assessment

• The 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines identify four patient groups who benefit from moderate- or high-intensity statin treatment, including those with a 10-year ASCVD risk ≥7.5% 4.
• A 10.6% risk of ASCVD would be considered moderate to high risk, and therefore, statin therapy would be recommended 4.