What is the recommended dosing of Crestor (rosuvastatin) for a patient with a history of myocardial infarction (MI)?

Dosing of Rosuvastatin for Patients with History of Myocardial Infarction

For patients with a history of myocardial infarction, rosuvastatin should be prescribed at a high-intensity dose of 20-40 mg daily to reduce mortality and prevent recurrent cardiovascular events. 1

Recommended Dosing Strategy

• High-intensity statin therapy is strongly recommended for all patients with a history of MI as part of secondary prevention 1
• Rosuvastatin 20-40 mg daily is considered high-intensity statin therapy and provides approximately 45-60% reduction in LDL-C 2, 3
• The TRIUMPH registry defines goal statin dosing for post-MI patients as achieving >75% of maximal statin potency, which for rosuvastatin is 20-40 mg daily 1
• Starting dose should typically be rosuvastatin 20 mg daily, with potential titration to 40 mg if needed to achieve LDL-C targets 2, 4

Target LDL-C Goals

• For patients with a history of MI, the target LDL-C should be less than 70 mg/dL 1, 2
• An even lower LDL-C target of less than 55 mg/dL may be considered for very high-risk patients 2
• If the initial LDL-C target is not achieved with rosuvastatin monotherapy, consider adding ezetimibe 10 mg daily 2

Monitoring and Follow-up

• Baseline lipid profile, liver function tests, and creatine kinase should be obtained before initiating therapy 1
• Follow-up lipid profile should be checked 4-12 weeks after initiating therapy to assess response 1
• Liver function tests should be monitored as clinically indicated (not routinely required) 1
• Assess for muscle symptoms at each follow-up visit 2

Special Considerations

• For patients unable to tolerate daily dosing due to myalgia or other side effects, alternative dosing strategies such as rosuvastatin 5-20 mg once weekly may be considered, though this is not the preferred approach 5
• For elderly patients or those with renal impairment, consider starting with a lower dose (5-10 mg) and titrating upward as tolerated 2
• Patients with severe renal impairment (not on hemodialysis) should not exceed 10 mg daily 2

Clinical Evidence Supporting High-Intensity Statin Therapy

• Despite guideline recommendations, only 27-35% of post-MI patients receive high-intensity statin therapy, representing a significant treatment gap 1
• High-intensity statin therapy after MI has been shown to reduce mortality, recurrent MI, and need for revascularization compared to moderate-intensity therapy 1
• The PROVE-IT TIMI 22 study demonstrated a 16% reduction in major cardiovascular events with high-intensity statin therapy (atorvastatin 80 mg) compared to moderate-intensity therapy (pravastatin 40 mg) in post-ACS patients 1
• A Chinese study showed that rosuvastatin 10 mg was more effective than simvastatin 40 mg in improving myocardial function and reducing carotid intima-media thickness in post-STEMI patients 4

Common Pitfalls to Avoid

• Underdosing statins is common - approximately 73% of post-MI patients receive suboptimal statin intensity 1
• Failure to initiate statin therapy before hospital discharge significantly reduces long-term adherence 1
• Discontinuing statin therapy due to mild side effects without attempting dose adjustment or alternative dosing strategies 5
• Focusing solely on LDL-C levels rather than using the appropriate intensity of statin therapy based on risk category 1
• Not reassessing patients initially deemed intolerant to statins for potential reintroduction of therapy 1, 5