When to initiate HMG-CoA reductase inhibitors (statins) therapy?

From the Guidelines

Statins should be started in individuals with established atherosclerotic cardiovascular disease (ASCVD), those with LDL cholesterol levels ≥190 mg/dL, adults aged 40-75 with diabetes, or individuals with an elevated 10-year ASCVD risk score (typically ≥7.5%). This recommendation is based on the most recent and highest quality evidence from the 2016 US Preventive Services Task Force recommendation statement 1.

Key Considerations

• The decision to initiate statin therapy should be based on a comprehensive assessment of the patient's risk factors, including dyslipidemia, diabetes, hypertension, and smoking.
• The 10-year ASCVD risk score should be calculated using the Pooled Cohort Equations to guide the initiation of statin therapy.
• Statins are typically taken indefinitely as cardiovascular benefits accumulate over time with continued use.
• Patients should be monitored for muscle pain and liver function should be checked periodically.

Statin Therapy Benefits

• Reduces the risk of cardiovascular events and mortality in individuals with established ASCVD or at high risk of developing ASCVD.
• Lowers circulating LDL cholesterol levels by 20-60% depending on the specific statin and dosage.
• Can be used for primary and secondary prevention of ASCVD.

Patient Selection

• Adults aged 40-75 with diabetes or an elevated 10-year ASCVD risk score (typically ≥7.5%).
• Individuals with established ASCVD or LDL cholesterol levels ≥190 mg/dL.
• Those with a history of smoking, dyslipidemia, hypertension, or other cardiovascular risk factors.

Monitoring and Follow-up

• Baseline liver function tests and lipid panels should be obtained before starting statin therapy.
• Patients should be monitored for muscle pain, which occurs in about 5-10% of users.
• Liver function should be checked periodically to minimize the risk of adverse effects.

From the Research

When to Start Statin Therapy

The decision to start statin therapy depends on various factors, including the patient's risk of atherosclerotic cardiovascular disease (ASCVD) and their individual characteristics.

• Patients with ASCVD are candidates for high-intensity statins, with a goal of reducing low-density lipoprotein cholesterol by 50% or greater 2.
• High-risk primary prevention patients, such as those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater, should be considered for statin therapy 2, 3.
• For adults aged 40 to 75 years with no history of CVD and who have one or more CVD risk factors (e.g., dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD event risk of 10% or greater, statin use has a moderate net benefit 3.
• The US Preventive Services Task Force recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have one or more CVD risk factors and an estimated 10-year CVD risk of 10% or greater 3.
• For adults aged 40 to 75 years with one or more CVD risk factors and an estimated 10-year CVD risk of 7.5% to less than 10%, the USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD 3.

Considerations for Statin Therapy

When considering statin therapy, clinicians should take into account the patient's individual characteristics, such as their risk factors, comorbidities, and potential for benefit or harm.

• The latest guidelines emphasize that treatment intensity should increase with increasing cardiovascular risk, and the decision to initiate intervention remains a matter of individual consideration and shared decision-making 4.
• Statin safety and tolerability have been extensively reviewed, and the benefits of statin therapy are believed to outweigh the risks for most patients 5.
• The risk of statin-induced serious muscle injury, hepatotoxicity, and newly diagnosed diabetes mellitus is relatively low, and there is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis 5.