Should Rosuvastatin be considered for a patient with cardiovascular disease and multiple comorbidities, including thalassemia minor, and if so, how should it be administered?

Rosuvastatin Therapy for an Elderly Male with Multiple Cardiovascular Comorbidities

Rosuvastatin therapy is strongly recommended for this patient with established cardiovascular disease and multiple risk factors, starting at 10 mg daily with careful monitoring for side effects. 1

Rationale for Statin Therapy

• This patient has established cardiovascular disease (CVD) with multiple high-risk comorbidities including aortic stenosis/regurgitation, mitral regurgitation, hypertension, and left bundle branch block (LBBB), making him an appropriate candidate for statin therapy 1
• High-intensity statin therapy is indicated for patients with established cardiovascular disease to reduce the risk of major adverse cardiovascular events 1
• The 2019 ACC/AHA guidelines specifically recommend statin therapy for patients with clinical ASCVD to reduce cardiovascular events and mortality 1

Dosing Considerations

• Start with rosuvastatin 10 mg daily rather than the maximum dose of 20-40 mg, given the patient's advanced age (early 70s) and multiple comorbidities 1, 2
• This moderate-intensity approach is supported by the CORONA trial, which demonstrated that rosuvastatin 10 mg daily reduced hospitalizations for cardiovascular causes in patients with ischemic heart failure 1
• The FDA-approved dosing for rosuvastatin indicates starting at lower doses for elderly patients and those with multiple comorbidities 2

Special Considerations for This Patient

• Thalassemia minor: While not a contraindication to statin therapy, requires monitoring of muscle symptoms as patients with hemoglobinopathies may have baseline myalgias 1
• Cardiac valve disease and LVH: These conditions increase cardiovascular risk and support the use of statin therapy 1
• Already on SGLT2 inhibitor (Dapagliflozin): This suggests possible diabetes or heart failure indication, both of which would further support statin therapy 1

Monitoring Protocol

• Check baseline liver function tests and creatine kinase before initiating therapy 1, 2
• Assess LDL-C levels 4-12 weeks after initiation to evaluate response 2
• Target LDL-C reduction of ≥50% from baseline or absolute level <1.4 mmol/L (55 mg/dL) per European guidelines 1
• Monitor for muscle symptoms, which occurred in 5.8% of patients in the HOPE-3 trial with rosuvastatin 10 mg 3
• Consider dose adjustment based on response and tolerability 1, 2

Potential Adjustments

• If LDL-C goal is not achieved with rosuvastatin 10 mg and the patient tolerates it well, consider increasing to 20 mg daily 1
• If muscle symptoms or other side effects occur, reduce dose to 5 mg daily 2
• If LDL-C remains elevated despite maximum tolerated rosuvastatin dose, consider adding ezetimibe as recommended by guidelines 1

Important Cautions

• Avoid concomitant use with medications that increase rosuvastatin levels (e.g., cyclosporine, gemfibrozil) 2
• Take special care with monitoring in elderly patients, who may be more susceptible to adverse effects 1, 2
• Administer rosuvastatin at least 2 hours before antacids containing aluminum and magnesium hydroxide 2

Expected Benefits

• Reduction in major adverse cardiovascular events (MACE) including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke 1, 3
• The HOPE-3 trial demonstrated that rosuvastatin 10 mg daily reduced cardiovascular events in intermediate-risk patients with a hazard ratio of 0.76 (95% CI, 0.64 to 0.91) 3
• Potential slowing of atherosclerotic progression, which is particularly important given the patient's multiple cardiovascular comorbidities 4