When should statins (HMG-CoA reductase inhibitors) be prescribed to patients?

Statin Prescription Guidelines

Statins should be prescribed for patients based on their cardiovascular risk profile, with specific recommendations for primary and secondary prevention according to established risk thresholds and clinical conditions. 1

Primary Prevention Recommendations

Adults 40-75 years without established ASCVD:

• High risk (≥20% 10-year ASCVD risk):

  • High-intensity statin therapy 1
  • Goal: ≥50% LDL-C reduction 1

• Intermediate risk (≥7.5% to <20% 10-year ASCVD risk):

  • Moderate-intensity statin therapy 1
  • Goal: ≥30% LDL-C reduction 1

• Borderline risk (5% to <7.5% 10-year ASCVD risk):

  • Consider moderate-intensity statin if risk-enhancing factors present 1
  • Coronary artery calcium (CAC) scoring can guide decision 1:
    • CAC = 0: Reasonable to withhold statin (reassess in 5-10 years)
    • CAC = 1-99: Consider statin for patients ≥55 years
    • CAC ≥100 or ≥75th percentile: Initiate statin therapy

Special Populations:

• Diabetes mellitus (age 40-75):

  • Moderate-intensity statin regardless of calculated risk 1
  • High-intensity statin if multiple ASCVD risk factors 1

• LDL-C ≥190 mg/dL (≥4.9 mmol/L):

  • Maximally tolerated statin therapy regardless of age or risk 1

Secondary Prevention Recommendations

• Established ASCVD (history of MI, stroke, TIA, stable/unstable angina, coronary/arterial revascularization, PAD):

  • High-intensity statin therapy 1
  • Goal: ≥50% LDL-C reduction 1

• Very high-risk ASCVD patients:

  • High-intensity statin plus consider ezetimibe if LDL-C remains ≥70 mg/dL 1
  • Consider PCSK9 inhibitor if LDL-C remains elevated despite maximally tolerated statin plus ezetimibe 1

• Acute Coronary Syndrome:

  • Initiate high-intensity statin therapy as early as possible during hospitalization 1, 2

Statin Intensity Guidelines

High-Intensity Statins (LDL-C reduction ≥50%):

• Atorvastatin 40-80 mg
• Rosuvastatin 20-40 mg

Moderate-Intensity Statins (LDL-C reduction 30-49%):

• Atorvastatin 10-20 mg
• Rosuvastatin 5-10 mg
• Simvastatin 20-40 mg
• Pravastatin 40-80 mg
• Lovastatin 40 mg
• Fluvastatin XL 80 mg
• Pitavastatin 1-4 mg

Monitoring and Follow-up

• Check lipid profile at baseline, 4-12 weeks after initiating therapy or dose change, and annually thereafter 1
• Assess liver enzymes at baseline and if symptoms develop 3
• Monitor for muscle symptoms and check creatine kinase if symptoms develop 3

Common Pitfalls to Avoid

1. Underutilization of high-intensity statins in high-risk patients, particularly by non-cardiology specialties 4, 5

2. Premature discontinuation of statin therapy, which can lead to adverse cardiovascular outcomes due to plaque destabilization 2

3. Failure to reassess and titrate statin dose if target LDL-C reduction is not achieved

4. Overlooking statin therapy in patients with normal or borderline LDL-C levels who still have high ASCVD risk

5. Neglecting to consider coronary artery calcium scoring for risk refinement in intermediate-risk patients 1

6. Inadequate attention to drug interactions, particularly with medications metabolized by cytochrome P450 3A4 6

By following these evidence-based guidelines, clinicians can appropriately prescribe statins to reduce cardiovascular morbidity and mortality in patients at risk for ASCVD.