What is the Atherosclerotic Cardiovascular Disease (ASCVD) risk that should consider statin therapy?

From the Guidelines

Statin therapy should be considered for individuals with an ASCVD risk score of 7.5% or higher over 10 years. For those with a risk score between 5% and 7.5%, statins may be considered based on additional risk factors, such as family history of premature ASCVD, LDL-C levels of 160 mg/dL or higher, metabolic syndrome, chronic kidney disease, and others 1.

Key Considerations

• Patients with established ASCVD, LDL cholesterol ≥190 mg/dL, or diabetes with an ASCVD risk ≥7.5% should definitely receive statin therapy.
• Common statins include atorvastatin (10-80 mg daily), rosuvastatin (5-40 mg daily), simvastatin (10-40 mg daily), and pravastatin (10-80 mg daily).
• Higher intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg are recommended for those with established ASCVD or very high risk.
• Moderate intensity statins are appropriate for most primary prevention cases.
• Statins work by inhibiting HMG-CoA reductase, reducing cholesterol synthesis in the liver and increasing LDL receptor expression, which lowers circulating LDL cholesterol.

Monitoring and Follow-up

• Regular monitoring of lipid levels and liver function tests is recommended after starting statin therapy.
• The goal of statin therapy is to reduce LDL-C levels by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk, levels should be reduced by 50% or more 1. Some key points to consider when evaluating the need for statin therapy include:
• The presence of risk-enhancing factors, such as family history of premature ASCVD, LDL-C levels of 160 mg/dL or higher, and metabolic syndrome.
• The use of coronary artery calcium scoring to improve risk stratification in patients with intermediate risk.
• The importance of a clinician-patient risk discussion to determine the best course of treatment.
• The need for regular monitoring and follow-up to assess adherence to therapy and adequacy of response. The most recent and highest quality study, 1, provides the strongest evidence for the consideration of statin therapy in individuals with an ASCVD risk score of 7.5% or higher over 10 years.

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 Atherosclerotic Cardiovascular Disease (ASCVD) risk that should consider statin therapy is 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
• At least one additional CV risk factor 2

From the Research

Atherosclerotic Cardiovascular Disease (ASCVD) Risk and Statin Therapy

The decision to consider statin therapy for the prevention of Atherosclerotic Cardiovascular Disease (ASCVD) is based on an individual's risk factors and overall risk score. According to the studies, the following points are considered when evaluating the ASCVD risk:

• Patients with a 10-year risk of 20% or greater are considered high-risk and are recommended for high-intensity statin therapy 3, 4.
• Patients with a 10-year risk of 7.5% to less than 20% may be considered for statin therapy, and coronary artery calcium scoring can be used to further assess their risk 3, 4.
• Patients with severe hypercholesterolemia, diabetes with associated risk factors, and those aged 40 to 75 years with a 10-year risk for ASCVD of 7.5% or greater are also considered high-risk 3, 4.

Statin Therapy Recommendations

The studies recommend the following:

• High-intensity statins are recommended for patients with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD 3, 4.
• Moderate- to high-intensity statins are recommended for patients with a 10-year risk of 7.5% or greater 4.
• The goal of statin therapy is to reduce low-density lipoprotein cholesterol (LDL-C) levels by 50% or greater in high-risk patients 3.
• Non-statin drugs, such as ezetimibe, may be added to statin therapy in patients with very high risk or those who do not tolerate high-intensity statins 3, 4.

Implementation and Adherence to Statin Therapy

The studies highlight the importance of:

• Calculating ASCVD risk scores in patients aged 40 to 75 years to guide initiation of statin therapy 5, 6.
• Increasing the use of high-intensity statins in high-risk patients 5.
• Improving adherence to statin therapy and achieving recommended LDL-C targets 7.
• Addressing barriers to lipid blood tests and treatment of increased ASCVD risk based on guidelines 6.