Should I start a statin on a 63-year-old man with hypertension (HTN) and a 10-year 20% coronary artery disease (CAD) risk?

Statin Therapy for Primary Prevention in a 63-Year-Old Man with Hypertension and 20% CAD Risk

Yes, a statin should be initiated in this 63-year-old man with hypertension and a 10-year CAD risk of 20% as he falls into a high-risk category that will significantly benefit from statin therapy for primary prevention. 1, 2

Risk Assessment and Recommendation

The patient presents with:

• Age: 63 years (within the 40-75 year range for primary prevention)
• Hypertension (cardiovascular risk factor)
• 10-year CAD risk of 20% (high risk)

Based on these factors:

• The USPSTF strongly recommends (Grade B recommendation) initiating a statin for primary prevention in adults aged 40-75 years with at least one cardiovascular risk factor (including hypertension) and a 10-year cardiovascular risk ≥10% 1
• This patient's 20% risk places him in the highest risk category, where the evidence for benefit is strongest 2
• Adults with a 20% or greater 10-year CVD event risk are most likely to benefit from statin therapy 1

Expected Benefits

Statin therapy in this high-risk patient would provide:

• Reduction in all-cause mortality by approximately 13-30% 1, 3
• Significant reduction in risk of major coronary events (27-38% reduction) 3, 4
• Reduction in risk of non-fatal myocardial infarction (37-38% reduction) 3, 4
• Reduction in risk of stroke (25-28% reduction) 3, 4

Statin Selection and Dosing

For primary prevention in this risk category:

• Start with a low to moderate-dose statin 1, 2
• Aim for LDL-C reduction of approximately 30-50% 2
• Appropriate options include:
  • Atorvastatin 10-20 mg daily
  • Rosuvastatin 5-10 mg daily
  • Simvastatin 20-40 mg daily
  • Pravastatin 40-80 mg daily 2

Important Considerations

1. Risk Calculator Accuracy: Current risk calculators (including the Strong Heart Study calculator) may overestimate cardiovascular risk, but this patient's 20% risk still places him well above the treatment threshold 1

2. Potential Side Effects:

   • Muscle pain is commonly reported but not necessarily causally related to statins in placebo-controlled trials 1, 2
   • Small increased risk of diabetes with high-dose statins, particularly in patients with pre-existing risk factors 2
   • No clear evidence of cognitive impairment with statin use 1

3. Monitoring:

   • Baseline liver function tests
   • Follow-up lipid panel after 4-12 weeks to assess response
   • Monitor for muscle symptoms

Real-World Evidence

Studies show that failure to prescribe statins to eligible high-risk patients results in:

• Higher rates of ASCVD events
• Increased mortality 5

In a large healthcare network study, over one-third of statin-eligible patients were not prescribed statin therapy, leading to greater incident ASCVD and mortality events 5

Conclusion

This 63-year-old man with hypertension and a 20% 10-year CAD risk clearly falls into the high-risk category that would benefit substantially from statin therapy. The evidence strongly supports initiating a low to moderate-dose statin for primary prevention in this patient to reduce his risk of cardiovascular events and mortality.