What are the guidelines for starting a statin (HMG-CoA reductase inhibitor) as secondary prevention?

From the Guidelines

Statins should be initiated as secondary prevention for all patients with established atherosclerotic cardiovascular disease (ASCVD), including those with prior myocardial infarction, stroke, transient ischemic attack, or peripheral arterial disease, with high-intensity statins recommended, specifically atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily, aiming to reduce LDL cholesterol by ≥50% from baseline, as supported by the most recent guidelines 1.

Key Recommendations

• High-intensity statin therapy is recommended for all patients with ASCVD, regardless of age, to reduce the risk of recurrent cardiovascular events 1.
• For patients with ASCVD who are at very high risk, defined as a history of multiple major ASCVD events or 1 major ASCVD event and multiple other high-risk conditions, an LDL-C threshold of 1.8 mmol/L (70 mg/dL) is recommended for adding a nonstatin medication, such as ezetimibe or a PCSK9 inhibitor, to maximally tolerated statin therapy 1.
• In patients aged >75 years, it is reasonable to continue statin treatment if already on therapy, and it may be reasonable to initiate statin therapy after discussion of potential benefits and risks 1.

Monitoring and Follow-up

• Regular monitoring includes liver function tests at baseline and as clinically indicated, with lipid panels at 4-12 weeks after initiation and then annually.
• The goal of statin therapy is to reduce LDL cholesterol by ≥50% from baseline, which has been shown to significantly lower the risk of recurrent cardiovascular events by approximately 20-30% 1.

Special Considerations

• For patients with potential drug interactions or intolerance, moderate-intensity statins may be appropriate, such as atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, or pravastatin 40-80 mg daily.
• Statin therapy is contraindicated in pregnancy, and caution should be exercised when prescribing statins to patients with a history of liver disease or other potential contraindications 1.

From the FDA Drug Label

To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor.

The guidelines for starting a statin (HMG-CoA reductase inhibitor) as secondary prevention are not explicitly stated in the provided drug labels. However, the labels do indicate that rosuvastatin is indicated to reduce the risk of major adverse cardiovascular events in adults without established coronary heart disease who are at increased risk of CV disease.

• The recommended dosage range for adults is 5 mg to 40 mg once daily 2.
• Patients with certain conditions, such as severe renal impairment or Asian patients, may require a lower initial dose and careful consideration of risks and benefits 2. However, the provided information does not directly address the guidelines for starting a statin as secondary prevention.

From the Research

Guidelines for Starting a Statin as Secondary Prevention

The guidelines for starting a statin (HMG-CoA reductase inhibitor) as secondary prevention are as follows:

• High-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD) [(3,4)]
• The goal of low-density lipoprotein cholesterol (LDL-C) reduction is 50% or greater 3
• Patients with ASCVD are candidates for high-intensity statins, unless there are safety concerns [(3,4)]
• Atorvastatin 40-80 mg and rosuvastatin 20-40 mg are considered high-intensity statins 4
• A moderate-intensity statin is recommended if there are safety concerns or age is greater than 75 years 4

Patient Selection

The selection of patients for statin therapy as secondary prevention involves:

• Identifying patients with ASCVD, including those with a history of stroke or other clinical ASCVD events 4
• Assessing the patient's risk factors, including age, diabetes, and hypercholesterolemia [(3,4)]
• Evaluating the patient's ability to tolerate high-intensity statin therapy 5

Additional Therapies

Additional therapies that may be considered for patients on statin therapy as secondary prevention include:

• Ezetimibe, which has been shown to further reduce ASCVD risk when added to background statin therapy [(3,4,6)]
• Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, which can reduce LDL-C by 50-60% above that achieved by statin therapy alone 6
• Combination therapy with a moderate-intensity statin and ezetimibe, which may be considered for patients who cannot tolerate high-intensity statin therapy 3