What would be a good statin to start a patient with elevated low-density lipoprotein (LDL) and total cholesterol levels, who is also a smoker, on?

Statin Selection for Patient with Elevated LDL and Smoking History

Atorvastatin 20-40 mg daily is the optimal statin to start for a patient with LDL of 138 mg/dL, total cholesterol of 214 mg/dL, who is also a smoker. This recommendation is based on the need for moderate to high-intensity statin therapy in this high-risk patient.

Risk Assessment and Treatment Rationale

This patient has multiple cardiovascular risk factors:

• Elevated LDL cholesterol (138 mg/dL) above target of <100 mg/dL
• Elevated total cholesterol (214 mg/dL)
• Smoking status (major risk factor)

The combination of smoking and dyslipidemia significantly increases atherosclerotic cardiovascular disease (ASCVD) risk. Guidelines recommend:

• Treatment with a statin medication for all patients with extracranial carotid or vertebral atherosclerosis to reduce LDL cholesterol below 100 mg/dL 1
• Patients who smoke cigarettes should be strongly advised to quit smoking and offered smoking cessation interventions 1
• For patients with LDL ≥130 mg/dL, intensify LDL-lowering therapy with statin 1

Specific Statin Recommendation

Why Atorvastatin?

1. Potency: Atorvastatin is a high-potency statin that can achieve 37-50% LDL reduction at 10-20 mg doses and 45-60% reduction at 40-80 mg doses 2
2. Efficacy for mixed dyslipidemia: Effective in reducing both cholesterol and triglyceride levels 3
3. Rapid action: Therapeutic response is seen within 2 weeks, with maximum response usually achieved within 4 weeks 2
4. Once-daily dosing: Improves adherence 2

Dosing Considerations:

• Start with atorvastatin 20 mg daily if targeting 30-50% LDL reduction
• Consider 40 mg daily if targeting >50% LDL reduction (especially given smoking status as additional risk factor)
• Dose can be adjusted after 4-6 weeks based on lipid panel results 1, 4

Treatment Algorithm

1. Initial therapy: Atorvastatin 20-40 mg once daily
2. Follow-up: Check lipid panel in 4-8 weeks to assess response 4
3. Target goal: LDL cholesterol <100 mg/dL (or <70 mg/dL if other high-risk features develop) 1
4. If target not achieved:
   • Increase atorvastatin dose up to 80 mg if tolerated
   • Consider adding ezetimibe if maximum tolerated statin dose doesn't achieve target 1

Additional Management Considerations

• Smoking cessation: Critical component of therapy; can increase HDL levels by up to 30% 4
• Lifestyle modifications: Recommend dietary changes (reduced saturated fat and cholesterol), regular physical activity, and weight management 1, 4
• Monitor for side effects: Check liver enzymes at baseline and 8-12 weeks after starting treatment 4
• Medication adherence: Emphasize importance of consistent statin use, as it's associated with improved survival even at very low LDL levels 5

Important Caveats

• If the patient develops diabetes or metabolic syndrome, consider pitavastatin as an alternative, which may have less impact on glucose metabolism 1
• If muscle symptoms develop, consider dose reduction or switching to an alternative statin
• For patients who cannot tolerate statins, bile acid sequestrants and/or niacin are reasonable alternatives 1

This approach prioritizes cardiovascular risk reduction through appropriate statin selection and dosing while addressing the patient's specific risk factors, particularly smoking.