Should a 77-year-old male with a history of pancreatic mass (pancreatic tumor) and subsequent surgery, who has hypercholesterolemia (elevated total cholesterol) with high low-density lipoprotein (LDL) cholesterol and normal blood pressure (BP), be initiated on a statin (HMG-CoA reductase inhibitor)?

From the Guidelines

This 77-year-old male with a history of pancreatic mass and significantly elevated LDL cholesterol level of 173 mg/dL should be started on a statin to reduce his risk of atherosclerotic cardiovascular disease (ASCVD) 1. Given his age and lipid profile, initiating a moderate-intensity statin such as atorvastatin 20 mg daily or rosuvastatin 10 mg daily is recommended. The patient's total cholesterol level of 255 mg/dL and triglycerides of 174 mg/dL also support the need for lipid-lowering therapy. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL, at a 10-year ASCVD risk of ≥7.5%, should start a moderate-intensity statin if a discussion of treatment options favors statin therapy. Although the patient is 77 years old, the guideline's emphasis on reducing LDL-C levels, especially in individuals with elevated cardiovascular risk, supports the initiation of statin therapy in this case. Before starting treatment, baseline liver function tests should be obtained, and these should be rechecked after 4-12 weeks of therapy along with a lipid panel to assess response 1. The patient should be counseled on potential side effects including muscle pain and advised to report any concerning symptoms. Additionally, lifestyle modifications should be implemented alongside medication, including a heart-healthy diet low in saturated fats, regular physical activity as tolerated, and weight management if needed. Statins work by inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis, thereby reducing LDL cholesterol production and increasing LDL receptor expression, which enhances clearance of LDL from the bloodstream, ultimately reducing cardiovascular event risk 1.

Key considerations in this patient's management include:

• Monitoring for potential side effects of statin therapy
• Regular assessment of lipid profiles to adjust therapy as needed
• Encouraging adherence to a heart-healthy lifestyle
• Considering the addition of other lipid-lowering therapies if the patient's LDL-C level remains elevated despite statin therapy 1
• Evaluating the patient's 10-year ASCVD risk to guide the intensity of statin therapy 1.

By initiating statin therapy and promoting lifestyle modifications, this patient's risk of ASCVD can be significantly reduced, improving his overall morbidity, mortality, and quality of life 1.

From the FDA Drug Label

Rosuvastatin tablets are used: to reduce the risk of major adverse cardiovascular (CV) events, such as death from cardiovascular disease, heart attack, stroke, or the need for procedures to improve blood flow to the heart called arterial revascularization, in adults who do not have known heart disease but do have certain additional risk factors along with diet to: lower the level of low-density lipoprotein (LDL-C) cholesterol or “bad” cholesterol in adults with primary hyperlipidemia.

The patient has a high total cholesterol level of 255 and an LDL level of 173, which indicates primary hyperlipidemia. Given the patient's history of pancreatic mass and surgery, as well as the absence of any other contraindications, starting a statin such as rosuvastatin may be beneficial to reduce the risk of major adverse cardiovascular events and lower LDL-C levels. However, the decision to start a statin should be made by a healthcare provider, taking into account the patient's overall medical history and current health status 2.

Key considerations:

• The patient's high LDL level and total cholesterol level
• The patient's history of pancreatic mass and surgery
• The potential benefits of statin therapy in reducing cardiovascular risk
• The need for a healthcare provider to evaluate the patient's overall medical history and current health status before making a decision about statin therapy.

From the Research

Patient Profile

• Age: 77
• Past medical history: Pancreatic mass with surgery
• Current medications: None
• Blood pressure: Normal range
• Smoking history: Never smoked
• Lipid profile: Total cholesterol 255, LDL 173, HDL 45, triglycerides 174

Statin Therapy Consideration

• The patient's high LDL level (173) and total cholesterol (255) indicate a potential need for lipid-lowering therapy 3, 4, 5
• The patient's past medical history of pancreatic mass and surgery does not directly influence the decision to start statin therapy, but it is essential to consider overall cardiovascular risk 6
• The patient's normal blood pressure and lack of smoking history are positive factors, but the high LDL level remains a concern 6

Treatment Options

• Statin monotherapy: Effective in lowering LDL levels, but may not be sufficient to reach target levels in all patients 3, 7, 4
• Combination therapy: Adding ezetimibe to a statin can provide additional LDL lowering and help patients reach target levels 3, 4, 5
• The choice of statin and dosage should be based on the patient's individual risk factors and potential side effects 7, 6

Adherence and Efficacy

• Adherence to statin therapy is crucial for effective LDL lowering and cardiovascular risk reduction 7
• Higher adherence to statin therapy is associated with greater LDL lowering, particularly in patients receiving high-intensity statins 7