Will starting blood pressure medication for a systolic blood pressure (SBP) of 130 mmHg improve my atherosclerotic cardiovascular disease (ASCVD) score, given my elevated low-density lipoprotein (LDL) cholesterol level of 113 mg/dL and reluctance to take a statin?

Blood Pressure Medication and ASCVD Risk Reduction

Starting blood pressure medication for an SBP of 130 mmHg will reduce your cardiovascular risk and improve outcomes related to your ASCVD score, but only if your calculated 10-year ASCVD risk is ≥10%. 1

Understanding When BP Medication Improves ASCVD Outcomes

The decision to start blood pressure medication at your SBP level depends critically on your overall cardiovascular risk, not just your blood pressure number alone:

High-Risk Patients (10-year ASCVD Risk ≥10%)

• BP medication is strongly recommended at SBP ≥130 mmHg and will reduce your risk of heart attack, stroke, heart failure, and cardiovascular death by approximately 20-30% for every 10 mmHg reduction in SBP. 1, 2
• The ACC/AHA guidelines provide Class I (strong) recommendation with Level A evidence for initiating BP-lowering medications at SBP ≥130 mmHg when 10-year ASCVD risk is ≥10%. 1
• Recent meta-analysis confirms that targeting SBP <130 mmHg significantly reduces major cardiovascular disease events (HR 0.78) and all-cause mortality (HR 0.89) compared to higher targets. 3

Lower-Risk Patients (10-year ASCVD Risk <10%)

• BP medication is NOT recommended until SBP reaches ≥140 mmHg if your calculated ASCVD risk is below 10%. 1
• At your current SBP of 130 mmHg with low ASCVD risk, lifestyle modifications alone are the appropriate first-line approach, with reassessment in 3-6 months. 1

Calculate Your ASCVD Risk First

You must calculate your 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations (available at http://tools.acc.org/ASCVD-Risk-Estimator/) to determine whether BP medication will meaningfully improve your cardiovascular outcomes. 1

The calculator requires:

• Age, sex, race
• Total cholesterol and HDL cholesterol (you mentioned LDL 113 mg/dL, but need these values)
• Systolic blood pressure (130 mmHg)
• Diabetes status
• Smoking status
• Current use of BP or cholesterol medications

1

Addressing Your LDL of 113 mg/dL Without Statin

Your reluctance to take a statin is noted, but this creates a clinical dilemma:

The Cholesterol Component of ASCVD Risk

• Your LDL of 113 mg/dL is above optimal levels and contributes significantly to your ASCVD risk calculation. 1, 4
• LDL cholesterol is predominantly associated with atherosclerotic cardiovascular events, particularly in patients who already have evidence of coronary atherosclerosis. 5
• Small dense LDL cholesterol is the most atherogenic lipoprotein parameter and strongly predicts future cardiovascular events. 6

The Problem With Treating Only Blood Pressure

• Treating BP alone while leaving LDL elevated at 113 mg/dL addresses only one component of your cardiovascular risk. 1, 4
• If your ASCVD risk is ≥10%, guidelines recommend BOTH BP control AND statin therapy for optimal risk reduction. 1
• For patients with 10-year ASCVD risk ≥10%, moderate-to-high intensity statin therapy is recommended to reduce LDL-C by at least 30-50%. 1, 7

What Happens If You Refuse Statin Therapy

• Your ASCVD risk score will remain elevated due to the untreated LDL component. 1, 4
• BP medication will provide partial risk reduction (addressing the hypertension component), but you will miss the additional 20-30% relative risk reduction that statins provide for cardiovascular events. 1, 4
• This is suboptimal management if your calculated ASCVD risk is ≥10%, as you're leaving substantial preventable cardiovascular risk unaddressed. 1, 4

Recommended First-Line BP Medications

If your ASCVD risk is ≥10% and BP medication is indicated, first-line options include:

• Thiazide or thiazide-like diuretics (chlorthalidone or hydrochlorothiazide)
• ACE inhibitors (such as enalapril or lisinopril)
• Angiotensin receptor blockers (ARBs) (such as candesartan or losartan)
• Calcium channel blockers (such as amlodipine)

1, 2

Target Blood Pressure Goal

• Target SBP <130 mmHg and DBP <80 mmHg for most adults under 65 years with treated hypertension. 1
• For adults ≥65 years, target SBP <130 mmHg is still recommended if tolerated. 1

Common Pitfall to Avoid

Do not assume that treating blood pressure alone will adequately address your ASCVD risk if you have multiple risk factors. Comprehensive cardiovascular risk reduction requires addressing ALL modifiable risk factors, including both blood pressure AND LDL cholesterol. 1, 4