What is the recommended statin (HMG-CoA reductase inhibitor) therapy for a 67-year-old female with elevated systolic blood pressure (hypertension) and no other known medical history or laboratory results?

Statin Recommendations for a 67-Year-Old Female with Hypertension

Initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) after calculating her 10-year cardiovascular disease risk, and start this therapy if her risk is ≥7.5% or if she has additional risk factors beyond hypertension. 1

Risk Assessment Required

Before making a definitive statin decision, you must calculate her 10-year atherosclerotic cardiovascular disease (ASCVD) risk, which requires:

• Lipid panel (total cholesterol and LDL-C levels) 2
• Smoking status 2
• Diabetes status 2
• Renal function (creatinine/eGFR to assess for chronic kidney disease) 2

Her systolic blood pressure of 140 mmHg places her in the hypertensive range requiring treatment per current guidelines 2, and this hypertension itself is a cardiovascular risk factor that influences statin decision-making 2.

Primary Prevention Statin Thresholds

For patients aged 65-75 years with hypertension:

• Start statin therapy if 10-year cardiovascular disease risk ≥20% according to the British Hypertension Society guidelines, provided total cholesterol is ≥3.5 mmol/L (135 mg/dL) 2
• The ACC/AHA guidelines use a lower threshold of ≥7.5% 10-year ASCVD risk for statin initiation 2
• The most recent 2024 ESC guidelines recommend combination BP-lowering treatment for confirmed hypertension (BP ≥140/90 mmHg) 2, and this patient clearly meets criteria for antihypertensive therapy

The discrepancy between guidelines reflects evolving evidence, but the more recent ACC/AHA threshold of 7.5% is more widely adopted in current practice 2.

Age-Specific Considerations

At age 67, this patient falls into a favorable age range for statin therapy:

• Statins reduce myocardial infarction risk by 40% and stroke by 24% in patients ≥65 years 1
• The relative risk reduction is similar across age groups, but absolute benefit may be greater due to higher baseline risk 1
• Guidelines support statin use up to at least age 80 years for primary prevention 2

Recommended Statin Intensity and Agents

Moderate-intensity statin therapy is the appropriate starting point for this patient 1:

• Atorvastatin 10-20 mg daily (achieves 30-49% LDL-C reduction) 1
• Rosuvastatin 5-10 mg daily (achieves 30-49% LDL-C reduction) 1

High-intensity statins are NOT indicated for primary prevention in this age group, as they carry higher risk of adverse effects without proven additional benefit 1, 3. High-intensity therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) is reserved for secondary prevention in patients with established ASCVD 2, 1.

Practical Implementation Algorithm

Step 1: Obtain lipid panel, assess for diabetes, check renal function, and document smoking status

Step 2: Calculate 10-year ASCVD risk using ACC/AHA risk calculator

Step 3: If risk ≥7.5% OR if she has diabetes OR if total cholesterol ≥5.0 mmol/L with risk ≥20%:

• Start atorvastatin 10 mg daily OR rosuvastatin 5 mg daily 1
• These agents can be dosed at any time of day for adherence 2

Step 4: Recheck lipid panel in 4-12 weeks after initiation 1

Step 5: Titrate to moderate-intensity dosing (atorvastatin 20 mg or rosuvastatin 10 mg) if needed to achieve LDL-C reduction of 30-49% 1

Monitoring and Safety

• Assess LDL-C levels 4-12 weeks after initiation or dose adjustment 1
• Monitor for myopathy symptoms (muscle pain, weakness, or tenderness), especially given her age and likely polypharmacy 1, 4
• Check baseline liver transaminases before starting therapy 5
• Annual lipid profiles once stable 1

Critical Pitfalls to Avoid

Do not withhold statins based solely on age – the evidence clearly supports benefit in patients aged 65-75 years 1, 3

Do not start with high-intensity statins – elderly patients have higher rates of adverse drug reactions with high-intensity therapy (4.59% vs 2.91% with moderate-intensity) 5, and no additional cardiovascular benefit has been demonstrated in this age group for primary prevention 3

Do not prescribe statins without first controlling blood pressure – the British Hypertension Society recommends blood pressure control to <150/90 mmHg before adding aspirin or statins for primary prevention 2, though this is an older guideline and the 2024 ESC targets are lower (120-129 mmHg systolic) 2

Avoid atorvastatin if significant drug interactions exist – atorvastatin is metabolized by CYP3A4 and has higher rates of liver enzyme elevation and muscle symptoms compared to rosuvastatin 5, 4. Rosuvastatin has minimal CYP450 interactions and may be preferred in patients on multiple medications 4, 6

Consider moderate-intensity statin plus ezetimibe as an alternative strategy if statin intolerance develops, as this combination shows similar cardiovascular benefits with lower discontinuation rates in elderly patients 7

Concurrent Aspirin Consideration

Low-dose aspirin (75 mg daily) should be considered if her blood pressure is controlled to <150/90 mmHg AND she has either target organ damage, diabetes, or 10-year cardiovascular disease risk ≥20% 2. However, aspirin for primary prevention has become more controversial in recent years and requires careful bleeding risk assessment 2.