Should caution be exercised when initiating statin (HMG-CoA reductase inhibitor) therapy for hypercholesterolemia in a patient with a history of stroke and remote spontaneous coronary artery dissection?

From the Guidelines

Caution should be taken when starting a statin for high cholesterol in a patient with stroke who has a history of spontaneous coronary artery dissection (SCAD), and a moderate-intensity statin like atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily may be preferable to high-intensity therapy initially. The decision to start statin therapy in this patient should involve a thorough risk-benefit analysis, considering the potential benefits of statins in reducing the risk of recurrent stroke and cardiovascular events, as well as the potential risks, including the theoretical effect of statins on arterial wall integrity 1. The 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults recommends the use of moderate- to high-intensity statin therapy for the primary prevention of ASCVD in adults with LDL-C 70-189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or higher 1. However, in patients with a history of SCAD, a more cautious approach may be warranted, and alternative cholesterol-lowering strategies such as ezetimibe 10 mg daily could be considered if statins are poorly tolerated. Close monitoring for muscle symptoms, liver function, and any chest pain is essential, with follow-up within 4-6 weeks of initiation. A cardiology consultation before starting therapy would be prudent to ensure the treatment plan accounts for both stroke prevention needs and the patient's SCAD history. Some key points to consider when making this decision include:

• The remote timing of the SCAD (10 years ago) is somewhat reassuring, as recurrence risk decreases over time
• The potential benefits of statins in reducing the risk of recurrent stroke and cardiovascular events
• The potential risks of statin therapy, including the theoretical effect on arterial wall integrity
• The importance of close monitoring and follow-up after initiating statin therapy
• The potential role of alternative cholesterol-lowering strategies, such as ezetimibe, in patients who are poorly tolerant of statins.

From the FDA Drug Label

Rosuvastatin tablets are an HMG Co-A reductase inhibitor (statin) indicated: ( 1) To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. The patient has a history of stroke and spontaneous coronary artery dissection, which are both CV events.

• The drug label indicates that rosuvastatin is used to reduce the risk of major adverse CV events, which includes stroke.
• However, it does not provide direct information about the safety of starting statin therapy in patients with a remote history of spontaneous coronary artery dissection. Given the patient's history of stroke and spontaneous coronary artery dissection, caution should be taken when starting statin therapy, as the label does not directly address this specific situation 2.

From the Research

Considerations for Starting Statin Therapy

• When considering starting statin therapy for high cholesterol in a patient with a history of stroke and spontaneous coronary artery dissection (SCAD), several factors should be taken into account 3.
• The patient's remote history of SCAD 10 years ago is an important consideration, as SCAD is a rare cause of acute coronary syndrome 4.
• Studies have shown that conservative medical management may be a preferable approach for patients with SCAD, especially in those with preserved vessel flow 5, 6.

Risk of Recurrent SCAD

• The risk of recurrent SCAD is a concern in patients with a history of SCAD, and statin therapy may not necessarily reduce this risk 5, 6.
• A study found that revascularization as an initial first-line approach was associated with an estimated additional risk of target vessel revascularization of 6.3% 5.
• Another study found that percutaneous coronary intervention (PCI) for SCAD was associated with high rates of technical failure, even in patients presenting with preserved vessel flow 6.

Individualized Treatment Approach

• The treatment decision for patients with SCAD should be individualized and based on both clinical and angiographic factors 5.
• A comprehensive management strategy should take into account the patient's overall clinical profile, including their history of stroke and SCAD, as well as their current cardiovascular risk factors 3.
• Guiding patients based on individual assessment, taking into consideration baseline physical activity habits, treatment, and risk factors, is crucial for optimal exercise prescription and patient safety 7.