What is the best management approach for a smoker with a 7.5% Atherosclerotic Cardiovascular Disease (ASCVD) risk who is not currently taking any medications?

Management of a Smoker with 7.5% ASCVD Risk

For a smoker with a 7.5% ASCVD risk who is not on medications, smoking cessation should be the first priority, followed by initiation of moderate-intensity statin therapy. 1

Smoking Cessation

Smoking is a critical modifiable risk factor that significantly increases cardiovascular risk. For smokers with ASCVD risk:

• Immediate smoking cessation intervention is essential - smoking increases risk of ischemic stroke by 25-50% 1
• Recommended approaches:
  • Use the 5 A's approach: Ask, Advise, Assess, Assist, and Arrange 1
  • Offer pharmacotherapy including:
    • Nicotine replacement therapy (patches, gum)
    • Varenicline (more effective than bupropion or NRT in achieving abstinence) 1
    • Bupropion (300 mg daily has shown 44.2% cessation rates vs 19.6% for placebo) 1
  • Provide referral to smoking cessation programs for structured support 1

Men under 60 who continue to smoke have a mortality risk 5.4 times higher than those who quit smoking 1. Smoking cessation can substantially reduce this risk within 5 years 1.

Lipid Management

With a 7.5% 10-year ASCVD risk:

• Initiate moderate-intensity statin therapy after clinician-patient risk discussion 1
• Target LDL-C reduction of at least 30% from baseline 1
• Consider risk-enhancing factors that would further support statin therapy:
  • Family history of premature ASCVD
  • Persistently elevated LDL-C ≥160 mg/dL
  • Metabolic syndrome
  • Chronic inflammatory disorders
  • High-risk ethnic groups 1

Blood Pressure Management

• Target blood pressure <130/80 mmHg 1
• If BP ≥140/90 mmHg:
  • Initiate antihypertensive therapy
  • Consider beta-blockers and/or ACE inhibitors as first-line agents 1
  • Add thiazides as needed to achieve target BP 1

Additional Lifestyle Modifications

• Diet: Recommend Mediterranean or DASH diet with emphasis on fruits, vegetables, whole grains, low-fat dairy, and limited saturated fats 1
• Physical activity: Prescribe 150 minutes of moderate-intensity exercise weekly 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm for men, <80 cm for women 1
• Even modest weight loss (7%) and physical activity (150 min/week) can reduce risk of developing diabetes by 58% 1

Risk Assessment Refinement

For patients with borderline or intermediate risk (5-19.9%), consider:

• Coronary Artery Calcium (CAC) scoring to further refine risk assessment 1, 2:
  • CAC = 0: May withhold statin (except in smokers)
  • CAC 1-99: Supports statin therapy
  • CAC ≥100: Definitely initiate statin therapy 2

Important note: Do not down-classify risk in patients who are smokers, even if CAC = 0, as smoking increases risk of non-calcified plaque and thrombosis 1, 2

Follow-up and Monitoring

• Reassess smoking status at each visit
• Monitor lipid profile 4-12 weeks after initiating statin therapy
• Regular BP monitoring
• Annual reassessment of overall ASCVD risk factors

Common Pitfalls to Avoid

1. Underestimating risk in smokers - smoking significantly increases cardiovascular risk even when other risk factors appear controlled
2. Delaying statin therapy - with 7.5% ASCVD risk and smoking, statin therapy is indicated
3. Focusing only on pharmacotherapy - lifestyle modifications remain foundational even with medication
4. Neglecting smoking cessation support - providing resources and follow-up significantly improves quit rates

The combination of smoking cessation and statin therapy in this patient with 7.5% ASCVD risk provides the most effective approach to reducing cardiovascular events and mortality.