What is the best tool to determine if a patient should be on a HMG-CoA reductase inhibitor (statin)?

From the Guidelines

The best tool to determine if a patient should be on a statin is the ASCVD (Atherosclerotic Cardiovascular Disease) Risk Calculator, which estimates a patient's 10-year risk of heart attack or stroke, as recommended by the 2019 guideline on the management of blood cholesterol 1.

Key Considerations

• Patients with a 10-year ASCVD risk score ≥7.5% are generally candidates for statin therapy, as are those with LDL cholesterol ≥190 mg/dL, diabetes mellitus with age 40-75, or established cardiovascular disease.
• When initiating statin therapy, medication selection should be based on risk category: high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) for highest risk patients, moderate-intensity statins (atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, or pravastatin 40-80mg daily) for intermediate risk, and low-intensity statins for lower risk patients.
• Beyond the calculator, clinical judgment remains important, considering family history, other risk factors, and patient preferences, as emphasized in the 2018 guideline on the management of blood cholesterol 1.

Clinical Judgment and Patient Preferences

• The 2015 clinician-patient risk discussion for atherosclerotic cardiovascular disease prevention highlights the importance of presenting evidence-based clinical guidelines in the context of clinical judgment and considering patient preferences and values 1.
• The 2013 ACC/AHA guideline on the treatment of blood cholesterol also emphasizes the need for clinical judgment and patient-centered care in determining the best approach for each individual patient 1.

Statin Therapy and Risk Reduction

• Statins work by inhibiting HMG-CoA reductase, reducing cholesterol synthesis in the liver and increasing LDL receptor expression, which lowers circulating LDL cholesterol and decreases cardiovascular event risk.
• The potential net clinical benefit of pharmacotherapy, including statins, should be discussed with patients, along with the potential risks and benefits, as outlined in the 2019 guideline on the management of blood cholesterol 1.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD 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 best tool to determine if a patient should be on a HMG-CoA reductase inhibitor (statin) is assessment of their individual risk factors for coronary heart disease (CHD) and cardiovascular (CV) disease, including factors such as:

• Age
• High-sensitivity C-reactive protein (hsCRP) levels
• Presence of multiple risk factors for CHD
• Presence of established CHD or CV disease
• LDL-C levels 2 3

From the Research

Determining Statin Eligibility

To determine if a patient should be on a HMG-CoA reductase inhibitor (statin), the following tools and considerations can be used:

• The 10-year atherosclerotic cardiovascular disease (ASCVD) risk score, as recommended by the American College of Cardiology/American Heart Association guidelines 4, 5, 6, 7
• The Predicting Risk of Cardiovascular Disease Events (PREVENT) equations, which can be used to estimate 10-year ASCVD risk 6
• The Korean Risk Prediction Model (KRPM), which can be used to calculate 10-year ASCVD risk in certain populations 8
• Electronic health record-based tools and workflows, which can facilitate the calculation and documentation of ASCVD risk scores 5, 7

Key Considerations

When determining statin eligibility, the following factors should be considered:

• The patient's 10-year ASCVD risk score, with scores ≥7.5% indicating eligibility for statin therapy 4, 5, 6
• The patient's low-density lipoprotein cholesterol (LDL-C) level, with levels <190 mg/dL indicating potential eligibility for statin therapy 8
• The presence of other cardiovascular risk factors, such as hypertension, diabetes, and smoking 4, 5, 6
• The potential benefits and risks of statin therapy, including the reduction of major adverse cardiovascular events (MACEs) in high-risk patients 4, 5, 8

Tools and Resources

Several tools and resources are available to support the determination of statin eligibility, including:

• Online interactive tools, such as those developed in the study by 5
• Electronic health record-based workflows and reminders, such as those implemented in the study by 7
• Guideline-based recommendations and summaries, such as those provided by the American College of Cardiology/American Heart Association 4, 5, 6, 7