From the Guidelines
A statin is strongly recommended for a 78-year-old with an ASCVD risk score of 52.1%, as this represents very high cardiovascular risk. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, patients older than 75 years of age with clinical ASCVD should be initiated on 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.
Key Considerations
- The patient's high ASCVD risk score indicates a significant benefit from statin therapy in reducing the risk of cardiovascular events.
- The goal of statin therapy is to achieve a 30% to 49% reduction in LDL-C levels, although a reduction of at least 50% from baseline is often targeted in very high-risk patients.
- High-intensity statins like atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily may be appropriate, but moderate-intensity options (atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg) may be considered based on tolerability concerns in older adults.
- Regular monitoring, including liver function tests at baseline and lipid panels every 3-6 months initially, then annually, is essential to minimize potential side effects such as muscle pain, which occurs in about 5-10% of patients.
Clinical Decision Making
The decision to initiate statin therapy in this patient should be based on a comprehensive evaluation of the potential benefits and risks, taking into account the patient's age, frailty, and preferences. However, given the high ASCVD risk score, the benefits of statin therapy in reducing cardiovascular risk are likely to outweigh the potential risks. As stated in the guideline, it is reasonable to continue high-intensity statin therapy in patients older than 75 years of age who are tolerating it, after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Statin Therapy for ASCVD
The use of statin therapy in patients with atherosclerotic cardiovascular disease (ASCVD) is a well-established practice, with numerous studies demonstrating its efficacy in reducing cardiovascular events and mortality 2, 3, 4, 5.
Risk Assessment and Statin Recommendation
For a 78-year-old patient with an ASCVD risk score of 52.1%, the decision to recommend statin therapy should be based on individualized risk assessment, taking into account the patient's overall health status, medical history, and potential risk factors 6.
Considerations for Elderly Patients
In elderly patients, the risk of statin-associated muscle symptoms (SAMS) is a concern, and moderate-intensity statin therapy with ezetimibe may be a suitable alternative to high-intensity statin monotherapy 2, 5.
Key Findings
- Moderate-intensity statin with ezetimibe combination therapy offers a lower risk of SAMS and similar LDL-C reduction in elderly patients with ASCVD, compared to high-intensity statin monotherapy 2.
- Statin therapy is 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.
- Alternative LDL cholesterol-lowering strategies, such as moderate-intensity statin with ezetimibe, may be comparable to high-intensity statin therapy in terms of efficacy and safety in patients with ASCVD 4.
Factors to Consider
When deciding on statin therapy for a 78-year-old patient with an ASCVD risk score of 52.1%, the following factors should be considered:
- The patient's overall health status and medical history
- The presence of risk-enhancing factors, such as traditional risk factors and novel biomarkers
- The potential risk of SAMS and other adverse effects
- The patient's ability to tolerate statin therapy and potential need for alternative LDL cholesterol-lowering strategies 2, 3, 4, 5, 6.