What statin for a 44-year-old male with HTN (Hypertension) on lisinopril with LDL (Low-Density Lipoprotein) 103 and triglycerides 281?

Statin Recommendation for 44-Year-Old Male with Hypertension

Initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) immediately, given this patient's hypertension and elevated triglycerides, which together constitute significant cardiovascular risk factors warranting treatment regardless of the LDL-C level of 103 mg/dL. 1, 2

Risk Assessment and Treatment Rationale

• This 44-year-old male with hypertension meets criteria for statin therapy based on age (40-75 years) and the presence of hypertension as a major cardiovascular risk factor, independent of his baseline LDL-C level 1
• The elevated triglycerides (281 mg/dL, which exceeds the 175 mg/dL threshold) serve as a risk-enhancing factor that further supports statin initiation 3
• The ACC/AHA guidelines recommend moderate-intensity statin therapy for patients aged 40-75 years with risk factors like hypertension, targeting a 30-50% LDL-C reduction 3, 2

Specific Statin Selection

Preferred options for moderate-intensity therapy:

• Atorvastatin 10-20 mg daily - provides 30-50% LDL-C reduction and dose-dependent triglyceride lowering of approximately 20-30% 3, 4
• Rosuvastatin 5-10 mg daily - equally effective alternative with similar LDL-C and triglyceride reduction 3, 5, 4

Rationale for Moderate-Intensity Selection

• All statins effectively reduce triglycerides in hypertriglyceridemic patients (baseline TG >250 mg/dL), with reductions proportional to their LDL-C lowering potency 4
• The triglyceride/LDL-C ratio remains constant across statins at approximately 0.5 for patients with baseline triglycerides 150-250 mg/dL and 1.2 for those >250 mg/dL 4
• Since this patient has TG of 281 mg/dL, expect approximately 22-37% triglyceride reduction with moderate-intensity statin monotherapy 3, 4

Drug Interaction Considerations

• Critical caveat: Verify no drug-drug interactions between the statin and lisinopril, though this combination is generally safe 3, 6
• The combination of lisinopril with rosuvastatin has been specifically studied and shown to be safe and effective in hypertensive patients 6

Monitoring and Follow-Up

• Obtain baseline lipid profile before initiating therapy (already available) 1, 2
• Recheck lipid panel at 4-12 weeks after initiation to assess response and medication adherence 1, 2
• Annual lipid monitoring thereafter once stable 1
• Monitor for statin-related adverse effects including myopathy and new-onset diabetes (approximately 0.3 excess cases per 100 patients per year) 7

Treatment Escalation Strategy

If triglycerides remain ≥500 mg/dL or LDL-C goals not met after 4-6 weeks:

• Intensify lifestyle modifications: very-low-fat diet (10-15% of calories), eliminate added sugars and alcohol, increase physical activity 3, 1
• Consider adding ezetimibe 10 mg daily if LDL-C remains elevated despite statin therapy 3
• For persistent severe hypertriglyceridemia (≥500 mg/dL), consider adding prescription omega-3 fatty acids (icosapent ethyl) or fibrate therapy 3

Essential Lifestyle Modifications

• Implement Mediterranean or DASH diet patterns 1
• Increase regular physical activity 1
• Weight management if overweight/obese 1
• Smoking cessation if applicable 3
• Optimize blood pressure control with current lisinopril therapy 1

Common Pitfalls to Avoid

• Do not delay statin therapy waiting for lifestyle modifications alone - the combination of hypertension and elevated triglycerides warrants pharmacotherapy now 1, 2
• Do not use low-intensity statins as they are not recommended unless the patient is intolerant of higher doses 3
• Do not ignore the triglycerides - while LDL-C is near goal, the elevated triglycerides represent additional cardiovascular risk requiring attention 3, 4
• Ensure the patient understands this is long-term therapy for cardiovascular risk reduction, not just cholesterol lowering 2