Atorvastatin in HFrEF with Normal Lipid Profile
Statins, including atorvastatin, are not routinely indicated for patients with HFrEF and normal lipid profiles, as major randomized controlled trials have not demonstrated mortality or morbidity benefit in this population. 1
Guideline Position
The current ACC/AHA/HFSA heart failure guidelines do not recommend initiating statins specifically for HFrEF management in patients without other indications for lipid-lowering therapy. 2 The focus of HFrEF treatment remains on the four foundational medication classes: ARNI/ACE inhibitor/ARB, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, which together provide approximately 73% mortality reduction over 2 years. 3, 4
Evidence Base
Lack of Benefit in Major Trials
- Two large randomized placebo-controlled trials specifically examining statins in established HFrEF patients failed to show mortality benefit, which has shaped current guideline recommendations. 1
Conflicting Observational Data
- More recent prospective cohort studies and meta-analyses have suggested potential benefits, including decreased mortality and cardiovascular hospitalization with statin treatment in HFrEF. 1
- One prospective study of 110 patients with advanced HFrEF (LVEF <30%) found atorvastatin 10 mg daily was associated with lower all-cause mortality (16% vs 36%, P=0.017) and reduced sudden cardiac death (5% vs 22%, P=0.012) compared to controls over 1 year. 5
Important Distinction: HFpEF vs HFrEF
- In contrast to HFrEF, observational studies in HFpEF patients have consistently shown positive associations between statin use and improved mortality, primarily through reductions in sudden death and noncardiovascular death. 6, 1
- This suggests the pathophysiology and statin responsiveness may differ between HFrEF and HFpEF populations. 6
Clinical Approach
When to Continue Statins
- If already prescribed for another indication (e.g., prior myocardial infarction, atherosclerotic cardiovascular disease, diabetes), continue the statin as it does not cause harm and may provide benefit. 1
When NOT to Initiate Statins
- Do not start statins solely for HFrEF management in patients with normal lipid profiles who lack other cardiovascular indications for lipid-lowering therapy. 1
- Prioritize optimization of the four foundational HFrEF medications (ARNI/ACE-I/ARB, beta-blocker, MRA, SGLT2 inhibitor) to target or maximally tolerated doses before considering any additional therapies. 4
Common Pitfalls
- Delaying guideline-directed medical therapy while focusing on statins or other non-evidence-based treatments in HFrEF. 4
- Discontinuing statins in patients who were already taking them for appropriate indications when HFrEF is diagnosed—this may worsen outcomes. 1
- Confusing HFpEF evidence with HFrEF—the two conditions have different responses to statin therapy. 6, 1