What is the best approach to initiate statin (HMG-CoA reductase inhibitor) therapy in a 74-year-old patient with acute striatocapsular infarct, chronic bilateral capsuloganglionic lacunar infarcts, and severe white matter microangiopathic changes, who is resistant due to a history of Spontaneous Coronary Artery Dissection (SCAD) and has a lipid profile showing elevated Low-Density Lipoprotein (LDL) and non-High-Density Lipoprotein (non-HDL) levels?

From the Guidelines

I would strongly recommend starting this 74-year-old patient on a high-intensity statin therapy, specifically atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily, despite her resistance. Her recent acute striatocapsular infarct, chronic bilateral lacunar infarcts, and severe white matter microangiopathic changes indicate significant cerebrovascular disease requiring aggressive secondary prevention. According to the 2024 recommendations on the optimal use of lipid-lowering therapy in established atherosclerotic cardiovascular disease and following acute coronary syndromes, statin therapy is a cornerstone of secondary prevention in patients with established cerebrovascular disease 1.

Her lipid profile shows elevated LDL (4.09 mmol/L) and non-HDL cholesterol (4.51 mmol/L), which are well above recommended targets for someone with established cerebrovascular disease. While her HDL is indeed high (2.25 mmol/L), this does not negate the risk posed by elevated LDL. The 2019 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol emphasizes the importance of reducing LDL-C levels in patients with clinical ASCVD, and recommends high-intensity statin therapy or maximally tolerated statin therapy to lower LDL-C levels by 50% 1.

The theoretical concern about statins increasing SCAD (spontaneous coronary artery dissection) risk is not supported by current evidence, and the clear benefit of statins in preventing recurrent stroke outweighs this theoretical risk. I would explain that statins work primarily by reducing LDL cholesterol and have anti-inflammatory effects that stabilize atherosclerotic plaques. For this patient with multiple vascular risk factors and established cerebrovascular disease, statin therapy represents a cornerstone of secondary prevention that could significantly reduce her risk of recurrent stroke and further cognitive decline.

Key points to consider when initiating statin therapy in this patient include:

• Starting with a high-intensity statin to achieve a significant reduction in LDL-C levels
• Monitoring for potential side effects, such as muscle pain or liver enzyme elevation
• Educating the patient on the importance of adherence to statin therapy and lifestyle modifications to reduce cardiovascular risk
• Regularly reviewing and adjusting the treatment plan as needed to ensure the patient is meeting their lipid targets and minimizing their risk of recurrent cardiovascular events.

From the FDA Drug Label

To reduce the risk of: Myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD Adults with primary hyperlipidemia As an adjunct to diet to reduce low-density lipoprotein (LDL-C)

The patient has a history of acute striatocapsular infarct and chronic bilateral capsuloganglionic lacunar infarcts, which indicates a high risk of stroke and coronary heart disease (CHD). The patient's LDL level is 4.09 mmol/L, which is elevated. Given the patient's history and current lipid profile, the best recommendation is to start a statin to reduce the risk of MI and stroke. The recommended starting dosage of atorvastatin is 10 or 20 mg once daily. However, considering the patient's high risk of CHD and stroke, a starting dose of 20 mg once daily may be more appropriate. It is essential to monitor the patient's liver enzymes and CK levels before initiating therapy and as clinically indicated thereafter to minimize the risk of myopathy and rhabdomyolysis. The patient's concern about SCAD risk should be addressed, and the benefits of statin therapy should be weighed against the potential risks. The patient should be informed of the risks and benefits of statin therapy and monitored closely for any adverse reactions. 2

From the Research

Patient's Condition and Statin Therapy

The patient is a 74-year-old woman with a history of acute striatocapsular infarct, chronic bilateral capsuloganglionic lacunar infarcts, and severe patchy bilateral cerebral hemispheric presumed white matter microangiopathic change. Her lipid profile shows an LDL of 4.09 mmol/L, non-HDL of 4.51 mmol/L, triglyceride of 1.08 mmol/L, and HDL of 2.25 mmol/L.

Considerations for Statin Therapy

• The patient is resistant to taking statins due to a prior history of SCAD 10 years ago and a cardiologist's decision to stop statin therapy due to theoretical recurrent SCAD risk.
• The patient believes her LDL is not concerning because her HDL is also high.
• According to 3, statins have proven their value in reducing cardiovascular events and mortality, and individualizing statin treatment can help minimize side effects and improve compliance.
• The USPSTF recommends statin therapy for primary prevention of CVD in adults aged 40 to 75 years with one or more CVD risk factors and an estimated 10-year CVD risk of 10% or greater, as stated in 4.

Recommendations for Statin Therapy

• Considering the patient's age and medical history, the decision to start statin therapy should be made after careful consideration of the potential benefits and harms, as suggested by 5 and 4.
• The patient's lipid profile and medical history should be taken into account when deciding on statin therapy, as stated in 6 and 7.
• A shared decision-making approach, as described in 5, may be helpful in discussing the potential benefits and harms of statin therapy with the patient and making an informed decision.
• The use of a decision aid, such as the one developed by the Mayo Clinic, may be helpful in promoting shared decision-making, as mentioned in 5.

Key Points to Consider

• The patient's prior history of SCAD and the cardiologist's decision to stop statin therapy should be carefully evaluated in the context of current guidelines and evidence, as stated in 3 and 4.
• The patient's lipid profile and medical history should be carefully considered when deciding on statin therapy, as stated in 6 and 7.
• A thorough discussion of the potential benefits and harms of statin therapy should be had with the patient, taking into account her individual circumstances and preferences, as suggested by 5 and 4.