Who is typically considered for statin (HMG-CoA reductase inhibitor) therapy?

Who Needs Statin Therapy

Statin therapy is recommended for adults with established atherosclerotic cardiovascular disease (ASCVD), adults with LDL-C ≥190 mg/dL, adults 40-75 years with diabetes, and adults 40-75 years with an estimated 10-year ASCVD risk ≥7.5% and risk factors. 1

Primary Prevention Candidates

High-Risk Primary Prevention

• Adults 40-75 years of age with LDL-C 70-189 mg/dL, without clinical ASCVD or diabetes, and with an estimated 10-year ASCVD risk ≥7.5% should receive moderate- to high-intensity statin therapy 1
• Adults 40-75 years with diabetes mellitus should receive moderate-intensity statin therapy regardless of estimated 10-year ASCVD risk 1
• Adults with primary LDL-C ≥190 mg/dL (≥4.9 mmol/L) should receive maximally tolerated statin therapy 1
• Adults with multiple ASCVD risk factors should be considered for high-intensity statin therapy with the aim to reduce LDL-C levels by 50% 1

Intermediate-Risk Primary Prevention

• It is reasonable to offer moderate-intensity statin therapy to adults 40-75 years with LDL-C 70-189 mg/dL, without clinical ASCVD or diabetes, and with an estimated 10-year ASCVD risk of 5% to <7.5% 1
• For adults with borderline risk (5-7.5% 10-year ASCVD risk), risk-enhancing factors may favor statin therapy initiation 1

Risk-Enhancing Factors

• Risk-enhancing factors include: family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dL, metabolic syndrome, chronic kidney disease, chronic inflammatory disorders, high-risk ethnic groups, persistent elevations of triglycerides ≥175 mg/dL, and elevated high-sensitivity C-reactive protein ≥2.0 mg/L 1
• In patients with intermediate risk where decision is uncertain after risk assessment, coronary artery calcium (CAC) scoring can guide therapy 1, 2

Secondary Prevention Candidates

• All adults with established clinical ASCVD should receive high-intensity statin therapy to reduce LDL-C levels by ≥50% 1
• Clinical ASCVD includes acute coronary syndromes, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin 1
• For patients older than 75 years with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of potential benefits, adverse effects, drug interactions, and patient frailty 1

Special Populations

Elderly Patients

• For patients >75 years with clinical ASCVD already on high-intensity statin therapy, it is reasonable to continue this therapy after evaluation of potential benefits, adverse effects, and drug interactions 1
• For primary prevention in adults >75 years, the evidence is insufficient to determine the balance of benefits and harms of initiating statin therapy 3

Patients with Diabetes

• Adults 40-75 years with diabetes mellitus should receive moderate-intensity statin therapy regardless of estimated 10-year ASCVD risk 1
• In adults with diabetes who have multiple ASCVD risk factors, high-intensity statin therapy is reasonable 1
• For adults with diabetes <40 years or >75 years, it is reasonable to evaluate potential ASCVD benefits and adverse effects when deciding to initiate, continue, or intensify statin therapy 1

Coronary Artery Calcium (CAC) Score-Based Decisions

• For patients with CAC = 0, statin therapy can be deferred in intermediate-risk patients without smoking, diabetes, or family history of premature coronary artery disease 2
• For patients with CAC = 1-99, statin treatment is favored, especially for those aged >55 years 2
• For patients with CAC ≥100 or ≥75th percentile, statin therapy is strongly recommended regardless of other risk factors 2

Statin Indications Based on FDA Labels

• Statins are indicated to reduce the risk of myocardial infarction, stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease 4, 5
• Statins are indicated as an adjunct to diet to reduce LDL-C in adults with primary hyperlipidemia 4, 5
• Statins are indicated for adults and pediatric patients with heterozygous familial hypercholesterolemia 4, 5

Common Pitfalls to Avoid

• Failing to continue statins in patients already taking them who are scheduled for noncardiac surgery 1
• Not considering statin therapy for patients undergoing vascular surgery regardless of clinical risk factors 1
• Overlooking the need for statin therapy in patients with hypertension who have a 10-year risk of cardiovascular death ≥5% based on risk assessment 1
• Underutilizing statins in eligible populations - studies show that 92.8% of individuals with isolated LDL-C ≥190 mg/dL and 41.5% of those with established ASCVD are not on statin therapy 6
• Focusing solely on LDL-C levels rather than overall cardiovascular risk when making statin therapy decisions 7

By following these evidence-based recommendations, clinicians can appropriately identify patients who would benefit from statin therapy to reduce their risk of cardiovascular events and mortality.