Should a 67-year-old patient with a QRISK3 score of 18.5%, total cholesterol of 4.4 mmol/L, and cholesterol/HDL ratio of 3.3 be considered for statin therapy?

Statin Therapy for a 67-Year-Old Patient with QRISK3 Score of 18.5%

Statin therapy is strongly recommended for this 67-year-old patient with a QRISK3 score of 18.5%, as they fall into the intermediate-risk category (≥7.5% to <20% 10-year ASCVD risk) where statins provide significant cardiovascular benefit. 1

Risk Assessment and Classification

• The patient's QRISK3 score of 18.5% places them in the intermediate-risk category (≥7.5% to <20% 10-year risk), making them a clear candidate for statin therapy according to current guidelines 1
• At age 67, the patient's age alone is a significant risk factor, though their total cholesterol of 4.4 mmol/L (170 mg/dL) and cholesterol/HDL ratio of 3.3 are relatively favorable 1
• For intermediate-risk patients, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines strongly recommend (Class I recommendation) initiating moderate-intensity statin therapy 1

Benefits of Statin Therapy in This Patient

• In intermediate-risk patients, statin therapy should aim to reduce LDL-C levels by 30% or more 1
• Statin therapy in this age group (66-75 years) has been well-represented in clinical trials and has demonstrated significant reduction in cardiovascular events 1
• The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) demonstrated that atorvastatin 10 mg daily reduced the rate of coronary events by 36% compared to placebo in patients with similar risk profiles 2
• The benefit of statin therapy in this age group outweighs potential risks, particularly given the patient's substantial 10-year risk score 1

Recommended Approach

1. Initiate moderate-intensity statin therapy (e.g., atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily) 1
2. Assess adherence and effects on lipid levels 4-12 weeks after initiation 1
3. Continue monitoring every 3-12 months thereafter 1
4. Aim for at least a 30% reduction in LDL-C levels 1

Considerations Specific to Age

• While age is a significant risk factor, the patient's 18.5% QRISK3 score represents a substantial risk that warrants intervention regardless of age 1
• For patients aged 66-75 years, there is strong evidence supporting statin therapy for primary prevention when 10-year risk exceeds 7.5% 1
• The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that statin therapy provides at least moderate net benefit for adults aged 40-75 years with a 10-year CVD risk of 10% or greater 1

Potential Alternative Approaches

• If there are concerns about initiating statin therapy immediately, coronary artery calcium (CAC) scoring could be considered to further refine risk assessment 1
• If CAC score is zero, it might be reasonable to withhold statin therapy and reassess in 5-10 years 1
• If CAC score is 1-99 in a patient ≥55 years of age (as in this case), statin therapy would still be recommended 1
• If CAC score is ≥100 or in the 75th percentile or higher, statin therapy would definitely be recommended 1

Potential Pitfalls and Caveats

• Do not dismiss statin therapy solely based on the patient's favorable lipid profile (total cholesterol 4.4 mmol/L, ratio 3.3), as their age and overall risk score still warrant treatment 1
• Avoid undertreatment, which is common in clinical practice despite clear evidence of benefit 3
• Be aware that while age significantly impacts risk calculation, the evidence for benefit in this age group is robust 1
• Do not delay treatment in intermediate-risk patients with QRISK3 >10% without compelling reasons, as early intervention provides greater lifetime benefit 1

In conclusion, this 67-year-old patient with a QRISK3 score of 18.5% should be started on moderate-intensity statin therapy with the goal of reducing their LDL-C by at least 30%, as this approach has been proven to reduce cardiovascular morbidity and mortality in this risk category.