What is the recommended statin for a patient with hypercholesterolemia, hypertriglyceridemia, and elevated LDL levels?

Recommended Statin for Hypercholesterolemia with Elevated Triglycerides

Start with moderate-intensity statin therapy using atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily, with strong consideration for atorvastatin given the elevated triglycerides (154 mg/dL). 1

Risk Assessment and Treatment Intensity

Your lipid panel shows:

• Total cholesterol: 221 mg/dL
• LDL-C: 144 mg/dL (above optimal)
• Triglycerides: 154 mg/dL (borderline high)

Without knowing your age and additional cardiovascular risk factors, the treatment approach depends on your risk stratification: 2

If You Are Age 40-75 Years Without ASCVD:

• Moderate-intensity statin therapy is recommended 2
• Atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily 1
• Target LDL-C reduction of 30-50% from baseline 2

If You Are <40 Years With Additional Risk Factors:

• Consider moderate-intensity statin therapy 2
• Same dosing as above 1

If You Have Established ASCVD:

• High-intensity statin therapy is mandatory 2
• Atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 1
• Target LDL-C reduction ≥50% from baseline 2

Why Atorvastatin May Be Preferred in Your Case

Atorvastatin has superior efficacy for both LDL-C and triglyceride reduction compared to other statins at equivalent doses: 3, 4

• Atorvastatin 10-20 mg reduces LDL-C by 37-43% 5
• Atorvastatin significantly reduces triglyceride-rich lipoproteins and small dense LDL particles, which are particularly atherogenic in patients with hypertriglyceridemia 3, 6
• In patients with baseline triglycerides >200 mg/dL, atorvastatin produces dose-dependent reductions in very low-density lipoprotein and remnant lipoproteins 3
• Atorvastatin increases LDL particle size and reduces oxidized LDL, both beneficial effects in mixed dyslipidemia 6

Alternative: Rosuvastatin

Rosuvastatin is equally acceptable and may provide slightly greater LDL-C reduction: 4, 5

• Rosuvastatin 10 mg achieves greater LDL-C reduction than atorvastatin 10 mg (52% vs 37%) 5
• Rosuvastatin 10 mg produces significantly greater triglyceride reductions than atorvastatin 10 mg in patients with hypertriglyceridemia 4
• 80% of patients on rosuvastatin 10 mg achieve NCEP ATP III LDL-C goals 5

Treatment Goals

Your LDL-C target depends on your overall cardiovascular risk: 2, 1

• High-risk patients (with ASCVD or diabetes): LDL-C <70 mg/dL with ≥50% reduction from baseline 1
• Moderate-risk patients: LDL-C <100 mg/dL 2
• Secondary target (non-HDL-C): 30 mg/dL higher than LDL-C goal 2

Monitoring Strategy

Obtain a fasting lipid panel 4-12 weeks after starting statin therapy to assess response and adherence: 2, 1

• If LDL-C goal is not achieved on maximally tolerated statin, add ezetimibe 10 mg daily 2, 1
• Reassess lipids every 3-12 months thereafter 2
• Monitor for statin-related adverse effects, particularly muscle symptoms 2

Concomitant Lifestyle Modifications

Lifestyle changes are essential and should be implemented immediately: 2

• Reduce saturated fat, trans fat, and cholesterol intake 2
• Increase dietary omega-3 fatty acids, viscous fiber, and plant stanols/sterols 2
• Increase physical activity (3-4 sessions weekly, 40 minutes per session, moderate-to-vigorous intensity) 1
• Weight loss if indicated 2, 1

Important Caveats

If you have diabetes, statin therapy is indicated regardless of baseline LDL-C level if you are age ≥40 years: 2

Statin therapy is contraindicated in pregnancy 2

If triglycerides remain >200 mg/dL after 3 months of statin therapy, consider adding fenofibrate or icosapent ethyl 1