What treatment is recommended for a 65-year-old male with hypercholesterolemia (elevated total cholesterol), elevated Low-Density Lipoprotein (LDL) cholesterol, and a high Atherosclerotic Cardiovascular Disease (ASCVD) risk score?

Statin Therapy for Primary Prevention in a 65-Year-Old Male with Elevated Cholesterol and 9.6% ASCVD Risk

Initiate moderate-intensity statin therapy immediately for this patient, as his 9.6% 10-year ASCVD risk exceeds the 7.5% threshold for statin initiation, and his age ≥65 years places him in a high-risk category where absolute cardiovascular benefit is substantial.

Risk Assessment and Treatment Indication

Your patient clearly qualifies for statin therapy based on multiple criteria:

• His 9.6% 10-year ASCVD risk exceeds the 7.5% threshold recommended by the ACC/AHA for initiating statin therapy in adults aged 40-75 years with LDL-C ≥70 mg/dL 1, 2

• Age ≥65 years is itself a high-risk condition that increases his cardiovascular risk and makes him eligible for more intensive prevention strategies 1

• His LDL-C of 142 mg/dL is in the range (70-189 mg/dL) where risk-based statin therapy decisions apply 1

The absolute benefit of statin therapy increases substantially with age because elderly individuals have higher baseline ASCVD risk, resulting in lower numbers needed to treat even if relative risk reduction is similar to younger patients 1

Recommended Statin Regimen

Start moderate-intensity statin therapy with one of the following options 1:

• Atorvastatin 10-20 mg daily, OR
• Rosuvastatin 5-10 mg daily, OR
• Simvastatin 20-40 mg daily, OR
• Pravastatin 40-80 mg daily

Moderate-intensity statins achieve 30-50% LDL-C reduction, which would lower his LDL-C from 142 mg/dL to approximately 71-99 mg/dL 1

Why Moderate-Intensity Rather Than High-Intensity?

• For primary prevention in patients ≥65 years without diabetes, moderate-intensity therapy is the standard recommendation 1

• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) should be considered if his ASCVD risk were ≥20% or if risk-enhancing factors are present 1, 2

• In elderly patients >75 years with clinical ASCVD, evidence for additional benefit from high-intensity versus moderate-intensity statins is limited, making moderate-intensity the preferred choice 1

Risk-Enhancing Factors to Consider

Before finalizing your treatment decision, assess for risk-enhancing factors that might favor more intensive therapy 1:

• Family history of premature ASCVD (men <55 years, women <65 years)
• Metabolic syndrome (waist circumference, triglycerides ≥150 mg/dL, blood pressure, glucose, HDL-C)
• Chronic kidney disease (eGFR 15-59 mL/min/1.73 m²)
• Chronic inflammatory conditions (psoriasis, rheumatoid arthritis, HIV/AIDS)
• Elevated high-sensitivity CRP (≥2.0 mg/L)
• Elevated lipoprotein(a) (≥50 mg/dL or ≥125 nmol/L)
• Current smoking status
• Hypertension or diabetes

If multiple risk-enhancing factors are present, consider high-intensity statin therapy to achieve ≥50% LDL-C reduction 1, 2

Role of Coronary Artery Calcium (CAC) Scoring

CAC scoring is NOT necessary in this patient because his ASCVD risk already exceeds 7.5%, making statin therapy clearly indicated 1

However, if you had uncertainty about treatment or if his risk were borderline (5-7.5%), CAC scoring could guide decisions 1, 2:

• CAC = 0: Could withhold statin therapy and reassess in 5-10 years (though less applicable at age 65)
• CAC 1-99: Favors statin initiation, especially at age ≥55 years
• CAC ≥100 or ≥75th percentile: Strongly indicates statin therapy

Treatment Goals and Monitoring

Target LDL-C reduction of at least 30% with moderate-intensity statin therapy, bringing his LDL-C from 142 mg/dL to <100 mg/dL 1, 2

Follow-Up Protocol:

1. Recheck lipid panel in 4-12 weeks after statin initiation to assess adherence and percentage LDL-C reduction 2

2. Monitor for adverse effects, particularly myalgia (0.7% discontinuation rate), diarrhea (0.5%), and hepatic enzyme elevations (0.7% with persistent elevations >3× ULN) 3

3. Check baseline ALT and CK before starting therapy, though routine monitoring is not required unless symptoms develop 3

4. If LDL-C remains ≥100 mg/dL on maximally tolerated statin, consider adding ezetimibe to achieve further 15-20% LDL-C reduction 1, 4

Patient Discussion Points

Before initiating therapy, engage in a clinician-patient risk discussion covering 1, 2:

• Potential ASCVD risk reduction: Approximately 20-30% reduction in cardiovascular events over 5 years 5
• Adverse effects: Muscle symptoms, hepatic enzyme elevations, new-onset diabetes (rare)
• Drug-drug interactions: Review current medications
• Patient preferences: Including quality of life considerations, as elderly patients often prioritize avoiding nonfatal MI or stroke over extending life 1
• Cost considerations: Generic statins are inexpensive and cost-effective

Common Pitfalls to Avoid

• Do not focus solely on cholesterol levels rather than overall cardiovascular risk when determining statin eligibility 5

• Do not delay treatment waiting for lifestyle modifications alone, as his age and risk level warrant pharmacotherapy now 1

• Do not use low-intensity statin therapy, as it is generally not recommended and provides insufficient LDL-C reduction 1

• Do not overlook the importance of lifestyle modifications alongside statin therapy—emphasize heart-healthy diet, physical activity, smoking cessation, and blood pressure control 1, 2

Practical Prescribing Recommendation

Order: Atorvastatin 10 mg by mouth once daily at bedtime

This provides a well-tolerated, moderate-intensity statin with proven cardiovascular benefit, generic availability, and once-daily dosing to enhance adherence 1, 3