Should statin (HMG-CoA reductase inhibitor) therapy be held in a patient with a history of coronary artery disease and stroke?

Statin Therapy in Patients with History of Coronary Artery Disease and Stroke

Statins should NOT be held in patients with a history of coronary artery disease and stroke, as discontinuation increases cardiovascular risk and worsens outcomes related to morbidity and mortality. 1

Benefits of Continuing Statin Therapy

• High-intensity statin therapy is recommended for patients with atherosclerotic ischemic stroke or transient ischemic attack (TIA) to reduce the risk of stroke and cardiovascular events 1
• Patients with a history of coronary artery disease and stroke are classified as "very high risk" for future atherosclerotic cardiovascular disease (ASCVD) events and derive significant benefit from statin therapy 1
• Discontinuation of statins in patients with acute coronary syndrome or those with established cardiovascular disease increases cardiovascular risk and should be avoided 2
• The SPARCL trial demonstrated that high-intensity statin therapy (atorvastatin 80 mg) reduced the risk of stroke by 16% in patients with previous stroke or TIA 1

Statin Selection and Dosing

• For patients ≤75 years of age with clinical ASCVD (including coronary artery disease and stroke), high-intensity statin therapy should be initiated or continued as first-line therapy 1
• High-intensity statin therapy includes atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 1
• For patients >75 years of age with clinical ASCVD, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits against adverse effects when determining statin intensity 1, 2
• Moderate-intensity statin therapy should be used when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present 1

Special Considerations

• For patients with a history of hemorrhagic stroke in addition to ischemic stroke/coronary artery disease, the decision to use statins requires careful consideration of risks and benefits 3
• In patients with a history of intracerebral hemorrhage who have an established indication for statin therapy (such as coronary artery disease), the risks and benefits must be weighed, but generally the cardiovascular benefits outweigh the potential risks 3
• For patients with multiple comorbidities or on multiple medications, monitor for potential drug interactions with statins, particularly medications that inhibit CYP3A4 1, 2
• Liver function tests should be monitored initially, approximately 12 weeks after starting therapy, then annually or more frequently if indicated 2

Potential Adverse Effects to Monitor

• Myopathy and rhabdomyolysis risk factors include age ≥65 years, uncontrolled hypothyroidism, renal impairment, and concomitant use of certain other drugs 4
• Patients should be instructed to promptly report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever 4
• Rare cases of immune-mediated necrotizing myopathy have been reported with statin use 4
• Hepatic dysfunction may occur with statin therapy; consider testing liver enzymes before initiating therapy and as clinically indicated thereafter 4

Treatment Goals

• The target LDL-C level for patients with established ASCVD (including stroke and coronary artery disease) should be <70 mg/dL (1.8 mmol/L) 1
• If LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy, it may be reasonable to add ezetimibe and then a PCSK-9 inhibitor if necessary 1
• A treat-to-target strategy (aiming for LDL-C between 50-70 mg/dL) has been shown to be noninferior to high-intensity statin therapy for clinical outcomes in patients with coronary artery disease 5

In conclusion, the evidence strongly supports continuing statin therapy in patients with a history of coronary artery disease and stroke, as the benefits for reducing morbidity and mortality significantly outweigh the risks.