From the Guidelines
Statin therapy should be initiated in patients with clinical atherosclerotic cardiovascular disease (ASCVD) who are 75 years of age or younger, with the aim of achieving a 50% or greater reduction in LDL-C levels, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline 1. When considering statin therapy, several factors should be taken into account, including the patient's age, ASCVD risk factors, and LDL-C levels.
- For patients with ASCVD who are 75 years of age or younger, high-intensity statin therapy is recommended to achieve a 50% or greater reduction in LDL-C levels 1.
- For patients with ASCVD who are older than 75 years of age, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences 1.
- In patients with diabetes aged 40-75 years at higher cardiovascular risk, high-intensity statin therapy is recommended to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL (<1.8 mmol/L) 1. Key considerations when initiating statin therapy include:
- Baseline liver function tests and creatine kinase levels should be checked before starting statin therapy.
- Patients should be monitored for side effects like muscle pain, which occurs in 5-10% of users.
- Regular follow-up every 3-12 months is recommended to assess efficacy and monitor for adverse effects. The decision to initiate statin therapy should be based on the individual patient's risk factors, medical history, and potential benefits and risks, with the goal of reducing cardiovascular event risk and improving quality of life 1.
From the Research
Initiation of Statin Therapy
The decision to initiate statin therapy depends on a patient's risk for atherosclerotic cardiovascular disease (ASCVD) 2, 3, 4.
- Patients at extreme ASCVD risk should be treated with high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol (LDL-C) of <55 mg/dL 2.
- Those at very high ASCVD risk should be treated to achieve LDL-C <70 mg/dL 2, 5.
- Treatment for moderate and high ASCVD risk patients may begin with a moderate-intensity statin to achieve an LDL-C <100 mg/dL, while the LDL-C goal is <130 mg/dL for those at low risk 2.
- The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend statin therapy based on patients' risk of an ASCVD event, rather than treating to specific lipid levels 4.
- For patients with no previous ASCVD event, risk calculators should be used to determine the 10-year risk of ASCVD, and statin therapy should be started if the risk is 7.5% or greater 4.
Patient Risk Assessment
Patient risk assessment is crucial in determining the initiation of statin therapy 3, 4.
- The ACC/AHA guideline recommends starting moderate- to high-intensity statins if the risk is 7.5% or greater 4.
- Patients with known ASCVD should receive high-intensity statins unless they fall into special categories (e.g., older age) or do not tolerate high-intensity statins, in which case moderate-intensity statins are appropriate 4.
- The choice and dose of statin have an impact both on the percentage LDL-C reduction and achievement of ≥50% reduction in LDL-C, overall and within each of the four statin benefit groups outlined by the 2013 ACC/AHA guidelines 3.
Combination Therapy
Combination therapy with statins and other lipid-lowering agents may be considered in certain patients 5, 6.
- The combination of a statin and a PCSK9 inhibitor was safe and more effective for the treatment of high-risk CVD patients, while the addition of ezetimibe was unable to significantly lower lipid levels any further 6.
- The outcomes of ezetimibe combination observed in the RACING trial were consistent among patients at very high risk of ASCVD 5.
- Discontinuation or dose reduction of the lipid-lowering drug due to intolerance occurred less frequently in the combination therapy group 5.