From the Guidelines
Statin therapy is generally not recommended for individuals with a low Framingham risk score (less than 10% 10-year risk of cardiovascular disease) unless specific additional risk factors are present, such as LDL cholesterol levels above 190 mg/dL, diabetes mellitus, strong family history of premature cardiovascular disease, or evidence of subclinical atherosclerosis. When considering statin therapy in low-risk individuals, it's essential to evaluate the presence of risk-enhancing factors, such as family history of premature ASCVD, persistently elevated LDL-C levels, metabolic syndrome, chronic kidney disease, and others 1. The decision to treat should involve shared decision-making, weighing potential benefits against risks of side effects like myalgias, liver enzyme elevations, and slightly increased diabetes risk. According to the 2021 guidelines, coronary artery calcium scoring (CACS) can be used to guide statin management in asymptomatic patients with various 10-year risk categories for ASCVD 1. For example, in patients with a low risk (<5%), a CACS of 0 and no family history of premature ASCVD and nonsmoker, lifestyle modification is recommended, whereas in those with an intermediate risk (7.5% to <20%), a CACS of 100 or patient in 75th percentile for age, sex, and race, moderate-intensity statin is recommended. When treatment is indicated, moderate-intensity statins like atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily are typically appropriate initial choices. It's crucial to consider the patient's preferences and values in the decision-making process, as well as to assess adherence to medications and lifestyle and percentage change in LDL-C level at 4 to 12 weeks after statin initiation or dosage adjustment 1. Ultimately, the goal of statin therapy is to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) by lowering LDL cholesterol levels, which can help prevent atherosclerotic plaque formation even in those with otherwise low calculated risk.
From the Research
Treatment of Low-Risk Framingham Score Patients with Statin
- The decision to treat a low-risk Framingham score patient with a statin is not straightforward and requires consideration of various factors beyond the Framingham Risk Score (FRS) 2.
- Current guidelines recommend considering a range of factors, including biochemical measurements and imaging studies, to determine whether the calculated FRS might be misleadingly low and whether statin therapy might be prudent 2.
- A study found that the new FRS increases the number of patients with low and intermediate scores who move to higher risk categories, leading to a 2.3-fold increase in the need for lipid-lowering treatment, including statin therapy 3.
- The relationship between low-density lipoprotein cholesterol and cardiovascular events is linear, suggesting that treating more patients with statins is likely to lead to a further reduction in cardiovascular events 3.
- Combination therapy with statins and other lipid-modifying agents, such as fibrates, may be effective in reducing cardiovascular morbidity in patients with high residual cardiovascular risk related to atherogenic dyslipidemia 4, 5.
- However, the benefits and risks of combination therapy compared with intensified statin monotherapy are unclear, and more research is needed to determine the optimal treatment strategy for low-risk patients 5.
- Emerging risk factors, such as family history of acute myocardial infarction, metabolic syndrome, and chronic kidney disease, can significantly impact cardiovascular risk assessment and may influence the decision to treat with statins 6.