Is asymptomatic aorta atherosclerosis on chest X-ray (CXR) or computed tomography (CT) scan an indication for statin therapy?

From the Guidelines

Atherosclerosis of the aorta detected incidentally on chest X-ray or CT scan without symptoms is not automatically an indication for statin therapy, but rather should be considered in the context of a comprehensive cardiovascular risk assessment, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The decision to start statins should be based on a thorough evaluation of the patient's risk factors, including age, gender, blood pressure, cholesterol levels, diabetes status, and smoking history, rather than solely on imaging findings. Current guidelines suggest using risk calculators like the ASCVD Risk Estimator Plus to determine the patient's 10-year risk of cardiovascular events. If the calculated risk exceeds 7.5-10%, statin therapy may be appropriate, with options including atorvastatin (10-80 mg daily), rosuvastatin (5-40 mg daily), or simvastatin (10-40 mg daily), as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. Some key points to consider in the decision-making process include:

• The presence of aortic atherosclerosis as a "risk enhancer" that might tip the decision toward statin therapy, especially in patients with borderline risk.
• The importance of baseline liver function tests and lipid panel before starting statins, as well as counseling patients about potential side effects like muscle pain.
• The rationale that atherosclerosis is a systemic process, and finding it in the aorta suggests the patient may have atherosclerosis elsewhere, potentially increasing their risk for cardiovascular events, as supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. In patients with evidence of aortic atherosclerosis, statin therapy at moderate or high intensity is recommended, according to the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. However, if there is no evidence of atherosclerosis, the use of statin therapy may be considered on a case-by-case basis, taking into account the patient's overall cardiovascular risk profile.

From the Research

Aorta Atherosclerosis and Statin Indication

• Aorta atherosclerosis detected on CXR or CT scan without symptoms may be an indication for statin therapy, as it suggests the presence of atherosclerotic disease 2, 3.
• The decision to initiate statin therapy should be based on the overall cardiovascular risk profile of the patient, including factors such as age, gender, family history, obesity, smoking, diabetes mellitus, and hypertension 4, 5.
• Current guidelines recommend the use of statins as first-line therapy for the prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with elevated low-density lipoprotein cholesterol (LDL-C) levels or those at high risk of ASCVD 4, 6.
• The use of high-intensity statin therapy has been shown to halt the progression and induce regression of coronary atheromatous plaques, while lowering cardiovascular disease event rates, even in patients with diabetes mellitus 6.

Lipid-Lowering Therapies

• Statins are the most commonly used lipid-lowering therapies and have been shown to reduce the risk of major adverse cardiovascular events (MACEs) and cardiovascular mortality 2, 3, 5.
• Ezetimibe and PCSK9 inhibitors are also effective in reducing LDL-C levels and lowering MACEs, and may be used in combination with statins in patients at very high risk of ASCVD 3, 4, 5.
• Fibrates and omega-3 fatty acids may also have a role in the management of diabetic dyslipidemia, but their effectiveness is still being studied 5.

Guideline-Concordant Therapies

• The use of guideline-concordant lipid-lowering therapies, including statins, ezetimibe, and PCSK9 inhibitors, has been increasing over time, with a significant increase in the use of high-intensity statins and combination therapies 4.
• The initiation and continuity of these therapies are important for the prevention of atherosclerotic cardiovascular disease, and healthcare providers should strive to improve the uptake of guideline-concordant therapies in their patients 4.