What adjustments should be made to a 73-year-old gentleman's medications, including atorvastatin (20mg), aspirin (325mg), and vitamin D3, given his hyperlipidemia and recent coronary artery calcium score?

Medication Management for a 73-Year-Old with Hyperlipidemia and CAC Score of 45

The aspirin dose should be decreased from 325 mg to 81 mg daily while maintaining the current atorvastatin dose of 20 mg. 1, 2

Aspirin Dose Adjustment

The current aspirin dose of 325 mg is higher than recommended for cardiovascular prevention in older adults. Current guidelines support using lower-dose aspirin (81 mg) for several reasons:

• Lower-dose aspirin (81 mg) provides similar cardiovascular protection with reduced bleeding risk compared to higher doses
• At 73 years of age, bleeding risk increases substantially with higher aspirin doses
• The patient's coronary artery calcium (CAC) score of 45 indicates mild atherosclerotic burden, which supports continued aspirin therapy but at a lower dose

Bleeding Risk Considerations

Older adults (>70 years) have increased risk of gastrointestinal and intracranial bleeding with higher-dose aspirin therapy, making the 81 mg dose more appropriate for this 73-year-old patient.

Statin Management

The current atorvastatin dose of 20 mg daily should be maintained for several reasons:

• The 2018 AHA/ACC guidelines recommend moderate-intensity statin therapy for primary prevention in older adults with risk factors 2
• Atorvastatin 20 mg is classified as moderate-intensity therapy, which reduces LDL-C by approximately 30-49% 2
• The patient's CAC score of 45 indicates the presence of subclinical atherosclerosis, supporting continued statin therapy
• The NICE Guidelines specifically recommend atorvastatin 20 mg daily for primary prevention in patients with cardiovascular risk factors 2

Why Not Change Atorvastatin?

• Decreasing to 10 mg would provide insufficient LDL-C reduction given the patient's established subclinical atherosclerosis
• Discontinuation would be inappropriate as the patient has documented atherosclerosis (CAC score 45)
• The current 20 mg dose is well within safety parameters for a 73-year-old with hyperlipidemia 1

Vitamin D3 Supplementation

The current vitamin D3 supplementation can be continued as there are no contraindications or interactions with the other medications.

Clinical Rationale

This approach balances cardiovascular risk reduction with safety considerations:

1. Maintains effective lipid-lowering therapy with atorvastatin 20 mg
2. Reduces bleeding risk by lowering aspirin dose while preserving antiplatelet benefit
3. Follows evidence-based guidelines for older adults with subclinical atherosclerosis

Common Pitfalls to Avoid

• Discontinuing aspirin completely: Despite bleeding risks, the patient's CAC score indicates atherosclerosis, supporting continued but lower-dose aspirin therapy
• Discontinuing statin: This would remove important cardiovascular protection in a patient with documented subclinical atherosclerosis
• Maintaining high-dose aspirin: The bleeding risk outweighs any marginal cardiovascular benefit of 325 mg vs. 81 mg in this age group

By reducing the aspirin dose to 81 mg daily while maintaining atorvastatin 20 mg, you optimize the benefit-risk profile for this 73-year-old patient with hyperlipidemia and mild coronary calcification.