What is the recommended approach to statin therapy in a 52-year-old male with elevated Low-Density Lipoprotein (LDL) cholesterol, normal High-Density Lipoprotein (HDL) cholesterol, and low triglycerides, who has a zero coronary artery calcium (CAC) score, and would Lipoprotein(a) (Lp(a)) or Apolipoprotein B (Apo B) testing be beneficial?

From the Guidelines

For a 52-year-old male with an LDL of 170 mg/dL, normal HDL, low triglycerides, and a calcium CT score of zero, statin therapy can be deferred with a focus on lifestyle improvements and management of other risk factors, with reassessment of CAC score in 5 years, as the CAC score of zero suggests a lower risk of ASCVD events 1. The patient's elevated LDL level of 170 mg/dL does increase the risk for atherosclerotic cardiovascular disease (ASCVD), but the absence of calcium in the coronary arteries, as indicated by a CAC score of zero, is a strong indicator of low cardiovascular risk 1. Additional testing with lipoprotein(a) [Lp(a)] or apolipoprotein B (apo B) may provide further insight into the patient's risk profile, but it is not necessary for the decision to initiate statin therapy in this case, as the CAC score is the most significant factor in determining the risk of ASCVD events 1. Some key points to consider in the management of this patient include:

• Lifestyle modifications, such as a heart-healthy diet, regular exercise, weight management if needed, and smoking cessation if applicable, should be strongly encouraged to reduce cardiovascular risk.
• The patient should be monitored regularly for changes in lipid profiles and other risk factors.
• If the patient's risk profile changes or if new evidence emerges, the decision to start statin therapy can be reevaluated.
• The use of CAC scoring as a tool for risk assessment and guiding statin therapy is supported by recent guidelines, which suggest that a CAC score of zero can be used to defer statin therapy in patients with intermediate or borderline risk 1. The decision to defer statin therapy should be made through shared decision-making, discussing the benefits of reducing cardiovascular risk versus the potential side effects of statin therapy, and taking into account the patient's preferences and values 1.

From the Research

Statin Therapy Recommendation

• For a 52-year-old male with an LDL of 170, normal HDL, and low triglycerides, and a calcium CT score of zero, the recommendation regarding statin therapy would depend on the individual's overall cardiovascular risk profile 2, 3.
• According to the studies, statins are recommended as first-line lipid-lowering agents, with a long history of efficacy and safety 2, 3.
• However, the decision to initiate statin therapy should be based on the patient's absolute cardiovascular risk, LDL-C level, and consensus LDL-C targets 2, 3.

Role of LP(a) and Apo B in Statin Therapy

• LP(a) and apo B may be helpful in assessing cardiovascular risk and guiding statin therapy 4.
• Apo B is considered a more accurate measure of cardiovascular risk and a better guide to the adequacy of lipid lowering than LDL-C or non-HDL-C 4.
• However, LDL-C is still widely used as the primary metric to guide statin/ezetimibe/PCSK9 therapy, despite the limitations of this approach 4.

Considerations for Statin Therapy

• The patient's calcium CT score of zero suggests a low burden of atherosclerotic plaque, which may influence the decision to initiate statin therapy 5.
• The studies suggest that statin therapy can be beneficial even in patients with normal LDL-C levels, particularly those with high cardiovascular risk 3, 6.
• However, the cost-effectiveness of statin therapy and the potential for adverse effects should also be considered in the decision-making process 6, 5.