Initial Statin Selection for Therapy
For patients requiring statin therapy, the recommended initial statin selection should be based on intensity requirements, with atorvastatin or rosuvastatin preferred for high-intensity therapy and simvastatin or pravastatin for moderate-intensity therapy. 1
Statin Intensity Selection Based on Patient Risk
- For primary prevention in adults aged 40-75 years without atherosclerotic cardiovascular disease (ASCVD), moderate-intensity statin therapy is recommended 1
- For patients with diabetes aged 40-75 years, moderate-intensity statin therapy is recommended, with high-intensity therapy considered reasonable if 10-year ASCVD risk ≥7.5% 1
- For adults with LDL-C ≥190 mg/dL, high-intensity statin therapy is recommended 1
- For adults ≤75 years with clinical ASCVD (secondary prevention), high-intensity statin therapy is recommended 1
- For adults >75 years with ASCVD, moderate-intensity statin therapy is recommended, with consideration of high-intensity therapy based on risk-benefit assessment 1
Specific Statin Recommendations
High-Intensity Options (≥50% LDL-C reduction)
- Atorvastatin 40-80 mg daily is a first-line high-intensity option 1, 2
- Rosuvastatin 20-40 mg daily is an alternative high-intensity option 1
- High-intensity statin therapy should be initiated within 24 hours of an acute coronary syndrome event 3
Moderate-Intensity Options (30-50% LDL-C reduction)
- Simvastatin 20-40 mg daily is an effective moderate-intensity option 1
- Pravastatin 40 mg daily is preferred in patients with potential drug interactions due to minimal CYP450 metabolism 3
- Fluvastatin is another hydrophilic statin with fewer drug interactions, particularly in transplant recipients 3
Comparative Effectiveness and Safety
- Rosuvastatin appears to provide greater LDL-C reduction compared to equivalent doses of atorvastatin 4
- High-intensity atorvastatin is associated with higher rates of adverse drug reactions compared to high-intensity rosuvastatin (4.59% vs 2.91%), including more frequent liver enzyme elevations and muscle symptoms 5
- Simulated clinical trials suggest improved cardiovascular outcomes with rosuvastatin compared to atorvastatin at equivalent intensity levels 6
- Switching from other statins to rosuvastatin 10 mg has demonstrated improved LDL-C goal achievement compared to continuing on atorvastatin 10 mg, simvastatin 20 mg, or pravastatin 40 mg 4
Special Populations
- For patients with severe renal impairment, pravastatin at a starting dose of 10 mg daily (maximum 40 mg daily) is recommended 1
- In elderly patients, particularly women over 80 years, starting with lower doses is recommended 1
- For liver transplant recipients, hydrophilic statins (fluvastatin, pravastatin) are preferred as they cause fewer metabolic interactions with immunosuppressants 3
- In patients with statin intolerance, alternate-day dosing of atorvastatin or rosuvastatin may be considered 7
Monitoring After Initiation
- Obtain lipid profile 4-12 weeks after statin initiation, after any dose change, and annually thereafter 1
- Monitor for side effects, particularly muscle symptoms 1
- Liver function tests should be monitored, especially with high-intensity therapy 2
Potential Pitfalls and Caveats
- Myopathy risk increases with age >65 years, renal impairment, hypothyroidism, and drug interactions 1
- Consider temporarily withholding statins during hospitalization for major surgery 1
- Statins are contraindicated in pregnancy, acute liver failure, or decompensated cirrhosis 1, 2
- Discontinuation of statin therapy in ACS patients at hospital admission has been associated with increased short-term mortality and major adverse cardiac events 3
- When switching between statins, consider equivalent doses to maintain therapeutic effect 4